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Preoperative Nomogram-Based Risk Stratification for Conversion to Open in Minimally Invasive Distal Pancreatectomy
Paul Wong MD1, Thomas E. Clancy MD1 1. Division of Surgical Oncology, Department of Surgery, Brigham and Women’s Hospital/Mass General Brigham
Background: Conversion to open during minimally invasive distal pancreatectomy (MIDP) is associated with increased perioperative morbidity. However, conversion risk is heterogeneous and challenging to quantify preoperatively. Methods: Retrospective review of the ACS-NSQIP (2014–2020) database was conducted of patients who underwent laparoscopic/robotic distal pancreatectomy. Patients were stratified based on conversion to open. Preoperative conversion predictors were identified, a nomogram was created to estimate conversion probability, and patients were categorized as low (<10%), intermediate (10–30%), and high (>30%) risk. Results: Of 7,234 patients, 1,230 (17.0%) required conversion. Higher BMI and ASA class, lower preoperative albumin, smoking, benign lesions >5cm, malignant T3/T4 tumors, and chronic pancreatitis were associated with conversion, whereas females and robotic approach were predictors of remaining MIDP (all p<0.05). Risk stratification identified 1,114 (20.8%) low-risk, 3,865 (72.3%) intermediate-risk, and 369 (6.9%) high-risk patients. Increasing risk was associated with greater postoperative complications (Low 17.4%, Intermediate 23.7%, High 37.1%; p<0.001). Regardless of risk, there were higher rates of intra-abdominal infections with conversion (Low: 16.9% vs. 9.6%, Intermediate: 13.4% vs. 9.5%, High: 20.6 vs. 6.9%; p<0.05). Low-risk patients who converted to open demonstrated greater complications than high-risk patients who remained MIDP (29.6% vs. 18.0%; p=0.036). Conclusion: We present a nomogram of preoperative factors to estimate conversion risk during MIDP and to highlight potential differences in morbidity across risk strata. This tool may facilitate patient counseling, operative planning, and intraoperative decision-making.
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