Incidence, associated risk factors, and impact of conversion to laparotomy in elective minimally invasive sigmoidectomy for diverticular disease
Benefits of minimally invasive surgical approaches to diverticular disease are limited by conversion to open surgery. A comprehensive analysis that includes risk factors for conversion may improve patient outcomes.
The US Premier Healthcare Database was used to identify patients undergoing primary elective sigmoidectomy for diverticular disease between 2013 and September 2015. Propensity-score matching was used to compare conversion rates for laparoscopic and robotic-assisted sigmoidectomy. Patient, clinical, hospital, and surgeon characteristics associated with conversion were analyzed using multivariable logistic regression, providing odds ratios for comparative risks. Clinical and economic impacts were assessed comparing surgical outcomes in minimally invasive converted, completed, and open cases.
The study population included 13,240 sigmoidectomy patients (8076 laparoscopic, 1301 robotic-assisted, 3863 open). Analysis of propensity-score-matched patients showed higher conversion rates in laparoscopic (13.6%) versus robotic-assisted (8.3%) surgeries (p < 0.001). Greater risk of conversion was associated with patients who were Black compared with Caucasian, were Medicaid-insured versus Commercially insured, had a Charlson Comorbidity Index ≥ 2 versus 0, were obese, had concomitant colon resection, had peritoneal abscess or fistula, or had lysis of adhesions. Significantly lower risk of conversion was associated with robotic-assisted sigmoidectomy (versus laparoscopic, OR 0.58), hand-assisted surgery, higher surgeon volume, and surgeons who were colorectal specialties. Converted cases had longer operating room time, length of stay, and more postoperative complications compared with minimally invasive completed and open cases. Readmission and blood transfusion rates were higher in converted compared with minimally invasive completed cases, and similar to open surgeries. Differences in inflation-adjusted total ($4971), direct ($2760), and overhead ($2212) costs were significantly higher for converted compared with minimally invasive completed cases.
Conversion from minimally invasive to open sigmoidectomy for diverticular disease results in additional morbidity and healthcare costs. Consideration of modifiable risk factors for conversion may attenuate adverse associated outcomes.
KeywordsDiverticulitis Sigmoidectomy Robotic-assisted surgery Laparoscopic surgery Colon resection Conversion
The authors wish to express their gratitude to Helen B. Hubert, PhD, consulting epidemiologist, for her assistance with manuscript preparation.
Compliance with ethical standards
Dr. Amir Bastawrous has received honoraria for courses, lectures, and proctoring from Intuitive Surgical, Inc. Dr. Robert Cleary has received honoraria for courses and lectures from Intuitive Surgical, Inc. Dr. Ron Landmann has received honoraria for teaching from Intuitive Surgical, Inc. Yuki Liu is a Health Economist and Data Scientist at Intuitive Surgical, Inc. Emelline Liu is the Director of Global Health Economics and Outcomes Research at Intuitive Surgical, Inc.
- 12.Bhakta A, Tafen M, Glotzer O, Canete J, Chismark AD, Valerian BT, Stain SC, Lee EC (2016) Laparoscopic sigmoid colectomy for complicated diverticulitis is safe: review of 576 consecutive colectomies. Surg Endosc 30(4):1629–1634. https://doi.org/10.1007/s00464-015-4393-5Epub 2015 Aug 15 CrossRefPubMedGoogle Scholar
- 13.Masoomi H, Moghadamyeghaneh Z, Mills S, Carmichael JC, Pigazzi A, Stamos MJ (2015) Risk factors for conversion of laparoscopic colorectal surgery to open surgery: does conversion worsen outcome? World J Surg 39(5):1240–1247. https://doi.org/10.1007/s00268-015-2958-z.10.1007/s00268-015-2958-z CrossRefPubMedGoogle Scholar
- 14.Silva-Velazco J, Stocchi L, Costedio M, Gorgun E, Kessler H, Remzi FH (2016) Is there anything we can modify among factors associated with morbidity following elective laparoscopic sigmoidectomy for diverticulitis? Surg Endosc 30:3541–3551. https://doi.org/10.1007/s00464-015-4651-6 CrossRefPubMedGoogle Scholar
- 19.In: Whitepapers - Premier Healthcare Database Whitepaper. https://learn.premierinc.com/i/790965-premier-healthcare-database-whitepaper/0. Accessed 27 Dec 2017
- 20.Becker C (2003) Time to pay for quality. CMS will partner with premier in trial project to give financial bonuses to hospitals that deliver the best care. Mod Healthc 33(26):6–7, 16, 11Google Scholar
- 21.Makadia R, Ryan PB (2014) Transforming the Premier Perspective® hospital database into the observational medical outcomes partnership (OMOP) Common Data Model. eGEMs 2(1)Google Scholar
- 27.Hadley J, Yabroff KR, Barrett MJ, Penson DF, Saigal CS, Potosky AL (2010) Comparative effectiveness of prostate cancer treatments: evaluating statistical adjustments for confounding in observational data. J Natl Cancer Inst 102:1780–1793. https://doi.org/10.1093/jnci/djq393 CrossRefPubMedPubMedCentralGoogle Scholar
- 44.Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N, Copeland J, Quirke P, West N, Rautio T, Thomassen N, Tilney H, Gudgeon M, Bianchi PP, Edlin R, Hulme C, Brown J (2017) Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR randomized clinical trial. JAMA 318(16):1569–1580CrossRefGoogle Scholar