Impact of the endoscopic surgical skill qualification system on conversion to laparotomy after low anterior resection for rectal cancer in Japan (a secondary analysis of the EnSSURE study)
Authors: Goto Koki , Watanabe Jun , Nagasaki Toshiya , Uemura Mamoru , Ozawa Heita , Kurose Yohei , Akagi Tomonori , Ichikawa Nobuki , Iijima Hiroaki , Inomata Masafumi , Taketomi Akinobu , Naitoh Takeshi ,   EnSSURE study group collaboratives in Japan Society of Laparoscopic Colorectal Surgery, Furutani Akinobu , Kanazawa Akiyoshi , Noda Akiyoshi , Ishibe Atsushi , Tani Chikayoshi , Yamamoto Daisuke , Fujita Fumihiko , Teraishi Fuminori , Ishida Fumio , Asahara Fumitaka , Karasawa Hideaki , Osawa Hideki , Nagano Hiroaki , Takeshita Hiroaki , Ota Hirofumi , Suwa Hirokazu , Ochiai Hiroki , Ogawa Hiroomi , Saeki Hiroshi , Hasegawa Hirotoshi , Bando Hiroyuki , Horie Hisanaga , Nagahara Hisashi , Hayashibara Kaori , Uehara Kay , Takehara Kazuhiro , Kojo Ken , Okamoto Ken , Saito Kenichiro , Ikeda Koji , Munakata Koji , Otsuka Koki , Hida Koya , Nagakari Kunihiko , Shimomura Manabu , Shiozawa Manabu , Takata Manabu , Yamamoto Manabu , Ito Masaaki , Numata Masakatsu , Watanabe Masahiko , Miguchi Masashi , Ozawa Mayumi , Takatsuki Mitsuhisa , Aisu Naoya , Sawada Naruhiko , Suzuki Nobuaki , Ikeshima Ryo , Inada Ryo , Oshima Ryuichi , Maruyama Satoshi , Kojima Shigehiro , Yamaguchi Shigeki , Homma Shigenori , Fujino Shiki , Mori Shinichiro , Ohnuma Shinobu , Takeda Sho , Aoyama Shota , Saito Shuji , Mukai Shunpei , Takahashi Shusaku , Sasaki Takahiro , Yamanashi Takahiro , Matsuda Takeru , Miura Takuya , Fukuoka Tatsunari , Ono Tatsunori , Kinjo Tatsuya , Shonaka Tatsuya , Godai Teni , Funakoshi Tohru , Adachi Tomohiro , Yamaguchi Tomohiro , Furuhata Tomohisa , Kimura Toshimoto , Aiba Toshisada , Fujiwara Toshiyoshi , Shimamura Tsukasa , Mizushima Tsunekazu , Iseki Yasuhito , Sumi Yasuo , Rino Yasushi , Kamada Yasuyuki , Kita Yoshiaki , Kakeji Yoshihiro , Takashima Yoshihiro , Ide Yoshihito , Sakai Yoshiharu , Munemoto Yoshinori , Akagi Yoshito , Ishii Yoshiyuki , Inoue Yuji , Kiyozumi Yuki , Kokuba Yukihito , Todate Yukitoshi , Suwa Yusuke , Sakimura Yusuke , Shimodaira Yusuke 
Published: March 2024

Abstract
Background and aims
Conversion to laparotomy is among the serious intraoperative complications and carries an increased risk of postoperative complications. In this cohort study, we investigated whether or not the Endoscopic Surgical Skill Qualification System (ESSQS) affects the conversion rate among patients undergoing laparoscopic surgery for rectal cancer.

Methods
We performed a retrospective secondary analysis of data collected from patients undergoing laparoscopic surgery for cStage II and III rectal cancer from 2014 to 2016 across 56 institutions affiliated with the Japan Society of Laparoscopic Colorectal Surgery. Data from the original EnSSURE study were analyzed to investigate risk factors for conversion to laparotomy by performing univariate and multivariate analyses based on the reason for conversion.

Results
Data were collected for 3,168 cases, including 65 (2.1%) involving conversion to laparotomy. Indicated conversion accounted for 27 cases (0.9%), while technical conversion accounted for 35 cases (1.1%). The multivariate analysis identified the following independent risk factors for indicated conversion to laparotomy: tumor diameter [mm] (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.01–1.05, p = 0.0002), combined resection of adjacent organs [+/−] (OR 7.92, 95% CI 3.14–19.97, p < 0.0001), and surgical participation of an ESSQS-certified physician [−/+] (OR 4.46, 95% CI 2.01–9.90, p = 0.0002). The multivariate analysis identified the following risk factors for technical conversion to laparotomy: registered case number of institution (OR 0.99, 95% CI 0.99–1.00, p = 0.0029), institution type [non-university/university hospital] (OR 3.52, 95% CI 1.54–8.04, p = 0.0028), combined resection of adjacent organs [+/−] (OR 5.96, 95% CI 2.15–16.53, p = 0.0006), and surgical participation of an ESSQS-certified physician [−/+] (OR 6.26, 95% CI 3.01–13.05, p < 0.0001).

Conclusions
Participation of ESSQS-certified physicians may reduce the risk of both indicated and technical conversion. Referral to specialized institutions, such as high-volume centers and university hospitals, especially for patients exhibiting relevant background risk factors, may reduce the risk of conversion to laparotomy and lead to better outcomes for patients.

Trial Registration
This study was registered with the Japanese Clinical Trials Registry as UMIN000040645.