Conversion during Minimally Invasive Left Pancreatectomy
Authors: De Ponthaud Charles , Nassar Alexandra , Dokmak Safi , Bertrand Thibaud , De Martino Julien , Pastier Clément , Castel Antoine , De Rosa Raffaele , Boubaddi Mehdi , Iben-Khayat Abdallah , Giannone Fabio , Jolly Elsa , Garnier Jonathan , Louis-Gaubert Clément , Mazzotta Alessandro D , André Marie , Gagnière Johan , Viennet Manon , Souche François-Régis , Kianmanesh Reza , Lupinacci Renato Micelli , Regimbeau Jean-Marc , Paye François , Addeo Pietro , Laurent Alexis , Vandermeulen Morgan , Caiazzo Robert , El Amrani Mehdi , Tresallet Christophe , Doussot Alexandre , Brunel Martin , Jouffret Lionel , Pinto Amandine , Valverde Alain , Romero Vece Rodolfo , Fara Régis , Mahfouf Samir , Darnis Benjamin , Chamakhi Amine , Thereaux Jeremie , Lubrano Jean , Girard Edouard , Veziant Julie , Birnbaum David Jérémie , Danion Jérôme , Corté Helene , Zemour Johanna , Piardi Tullio , de Carbonnières Anne , Ragot Emilia , Zarzavadjian Le Bian Alban , David Patrice , Brunaud Laurent , Lermite Emilie , Chreim Laura , Charlaix Ana Lucia , Gugenheim Jean , Schwarz Lilian , Bigourdan Jean Marc , Le Roy Bertrand , Karam Elias , Rhaiem Rami , Fabre Jean-Michel , Lequeu Jean-Baptiste , Noirault Marie , Ayav Ahmet , Soubrane Olivier , Regenet Nicolas , Turrini Olivier , Muscari Fabrice , Pessaux Patrick , Thébault Baudouin , Laurent Christophe , Sulpice Laurent , Sauvanet Alain , Fuks David , Gaujoux Sébastien ,   for the AFC- study group
Published: February 2025

Objectives:
To identify risk factors for conversion, develop a predictive Conversion Risk Score (CRS), and assess the association between conversion and severe postoperative complications.

Background:
Conversion occurs in 15-30% of minimally invasive left pancreatectomies (MILP). Risk factors and potential negative impacts on postoperative outcomes are poorly described.

Methods:
Retrospective, nationwide, multicenter study including all MILP (laparoscopy and robot) performed between 2010 and 2021. Risk factors for conversion were identified by multivariate mixed model, and a CRS was developed on a “training-set” and validated (calibration diagrams and ROC curves) on a “validation-set.” The association between severe complications and conversion was assessed using a propensity score based on the main risk factors for severe complications: age, sex, BMI, ASA score, tumor malignancy, multi-organ resection, operative duration, blood loss, splenectomy.

Results:
2104 patients included from 55 centers. Conversion occurred in 15.6% of MILP. Its risk factors were male sex (OR=1.67;P=0.048), BMI≥25 kg/m2 (OR=2.15;P=0.004), history of laparotomy (OR=2.9;P<0.001), initial pancreatitis (OR=3.58;P=0.007), tumor size≥40 mm (OR=2.12;P=0.003), planned splenectomy (OR=2.63;P<0.001), unplanned splenectomy (OR=4.05;P=0.028), portal vein resection (OR=36.3;P=0.002), multi-organ resection (OR=12.97;P<0.001). A predictive CRS was created based only on preoperatively available variables (the first six), with scores ranging from 0 to 7, corresponding to a conversion risk of 2% to 100%. No association was observed with tumor malignancy, robotic approach, or pancreatectomy volume. Conversion was significantly associated with severe complications [OR=1.80(1.16-2.54)], independent of other risk factors for complications.

Conclusions:
Conversion during MILP can be predicted by CRS, aiding surgeons in decision-making, given its significant association with severe complications.