CONVERSION TO OPEN IN LAPAROSCOPIC COLECTOMIES IN PATIENTS WITH CROHN'S DISEASE: IMPACT ON POSTOPERATIVE LEAK AND MORBIDITY
Rebecca Sahyoun*, George Q. Zhang, Miloslawa Stem, Brian D. Lo, Jonathan Efron, Chady Atallah, Bashar Safar
Surgery, John Hopkins Hospital, Baltimore, MD
Introduction:
Minimally invasive approaches have been shown to fast-track postoperative recovery by decreasing morbidity and length of stay (LOS) in many disease states including Crohn’s disease (CD). This perceived upside is appealing, but limiting in CD, because of significantly higher conversion rates as compared to other diseases. The aim of this study was to assess the impact of conversion to open resections on postoperative anastomotic leak (AL) and overall morbidity, and to identify risk factors associated with conversion.
Methods and Procedures:
All elective colectomies with a CD indication were identified using the American College of Surgeon’s National Surgical Quality Improvement Program database (2012-2018). Cancer, diverticular disease, and ulcerative colitis diagnoses were excluded. Patients were stratified according to the operative approach into 3 groups: open, lap completed, and lap requiring conversion to open resection. Primary outcomes were 30-day postoperative AL and overall morbidity. Multivariable logistic regression analysis was performed to assess the impact of conversion to open resections on the primary outcomes and to identify risk factors associated with the conversion.
Results:
Among 7932 colectomies, 3502 were performed via open approach, 3423 were completed laparoscopically, and 1007 were converted from lap to open resection. The conversion rate among all lap cases was 22.73%. In the unadjusted analysis, AL rate in the lap completed group was comparable to the conversion group but greater than in the open group (10.31% vs 12.21%, p=0.087; 10.31% vs 5.17%, p<0.001; respectively). The open approach was associated with the lowest AL rate (5.17%). After adjusting for other factors, the conversion to open resection was identified as an independent risk factor for both AL and morbidity (Table 1). Consequently, open approach was associated with a decreased risk of AL when compared to the conversion group. Risk factors associated with unplanned conversion included concurrent fistula, stoma creation, concurrent organ removal (gynecological and small bowel resections), increasing age, BMI≥30, hypertension, and female sex (Table 2).
Conclusion:
Unplanned conversion to open colectomy among CD patients is associated with significantly increased risk of postoperative AL and morbidity. With the aforementioned risk factors identified, a better risk stratification method is needed to determine who should have lap or open approach.
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