Top

Published in:

Open Access 08-03-2024 | Laparotomy

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: Koki Goto, Jun Watanabe, Toshiya Nagasaki, Mamoru Uemura, Heita Ozawa, Yohei Kurose, Tomonori Akagi, Nobuki Ichikawa, Hiroaki Iijima, Masafumi Inomata, Akinobu Taketomi, Takeshi Naitoh, EnSSURE study group collaboratives in Japan Society of Laparoscopic Colorectal Surgery

Published in: Surgical Endoscopy | Issue 5/2024

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.

Kang SB, Park JW, Jeong SY, Nam BH, Choi HS, Kim DW, Lim SB, Lee TG, Kim DY, Kim JS, Chang HJ, Lee HS, Kim SY, Jung KH, Hong YS, Kim JH, Sohn DK, Kim DH, Oh JH (2010) Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 11:637–645PubMedCrossRef

van der Pas MH, Haglind E, Cuesta MA, Fürst A, Lacy AM, Hop WC, Bonjer HJ (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14:210–218PubMedCrossRef

Fleshman J, Branda M, Sargent DJ, Boller AM, George V, Abbas M, Peters WR Jr, Maun D, Chang G, Herline A, Fichera A, Mutch M, Wexner S, Whiteford M, Marks J, Birnbaum E, Margolin D, Larson D, Marcello P, Posner M, Read T, Monson J, Wren SM, Pisters PW, Nelson H (2015) Effect of laparoscopic-assisted resection vs open resection of stage ii or iii rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA 314:1346–1355PubMedPubMedCentralCrossRef

Stevenson AR, Solomon MJ, Lumley JW, Hewett P, Clouston AD, Gebski VJ, Davies L, Wilson K, Hague W, Simes J (2015) Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA 314:1356–1363PubMedCrossRef

Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES, Lacy AM, Bemelman WA, Andersson J, Angenete E, Rosenberg J, Fuerst A, Haglind E (2015) A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 372:1324–1332PubMedCrossRef

Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, Choi HS, Kim DW, Chang HJ, Kim DY, Jung KH, Kim TY, Kang GH, Chie EK, Kim SY, Sohn DK, Kim DH, Kim JS, Lee HS, Kim JH, Oh JH (2014) Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 15:767–774PubMedCrossRef

Fleshman J, Branda ME, Sargent DJ, Boller AM, George VV, Abbas MA, Peters WR Jr, Maun DC, Chang GJ, Herline A, Fichera A, Mutch MG, Wexner SD, Whiteford MH, Marks J, Birnbaum E, Margolin DA, Larson DW, Marcello PW, Posner MC, Read TE, Monson JRT, Wren SM, Pisters PWT, Nelson H (2019) Disease-free survival and local recurrence for laparoscopic resection compared with open resection of stage II to III rectal cancer: follow-up results of the ACOSOG Z6051 randomized controlled trial. Ann Surg 269:589–595PubMedCrossRef

Stevenson ARL, Solomon MJ, Brown CSB, Lumley JW, Hewett P, Clouston AD, Gebski VJ, Wilson K, Hague W, Simes J (2019) Disease-free survival and local recurrence after laparoscopic-assisted resection or open resection for rectal cancer: the Australasian laparoscopic cancer of the rectum randomized clinical trial. Ann Surg 269:596–602PubMedCrossRef

Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365:1718–1726PubMedCrossRef

10.

Yamamoto S, Fukunaga M, Miyajima N, Okuda J, Konishi F, Watanabe M (2009) Impact of conversion on surgical outcomes after laparoscopic operation for rectal carcinoma: a retrospective study of 1073 patients. J Am Coll Surg 208:383–389PubMedCrossRef

11.

Agha A, Fürst A, Iesalnieks I, Fichtner-Feigl S, Ghali N, Krenz D, Anthuber M, Jauch KW, Piso P, Schlitt HJ (2008) Conversion rate in 300 laparoscopic rectal resections and its influence on morbidity and oncological outcome. Int J Colorectal Dis 23:409–417PubMedCrossRef

12.

Keller DS, Khorgami Z, Swendseid B, Champagne BJ, Reynolds HL Jr, Stein SL, Delaney CP (2014) Laparoscopic and converted approaches to rectal cancer resection have superior long-term outcomes: a comparative study by operative approach. Surg Endosc 28:1940–1948PubMedCrossRef

13.

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 318:1569–1580PubMedPubMedCentralCrossRef

14.

Furnée EJB, Aukema TS, Oosterling SJ, Borstlap WAA, Bemelman WA, Tanis PJ (2019) Influence of conversion and anastomotic leakage on survival in rectal cancer surgery; retrospective cross-sectional study. J Gastrointest Surg 23:2007–2018PubMedCrossRef

15.

Sekkat H, Souadka A, Courtot L, Rafik A, Amrani L, Benkabbou A, Peyrafort P, Giger-Pabst U, Karam E, Mohsine R, Majbar AM, Ouaissi M (2022) Available prediction scores of conversion for laparoscopic rectal cancer surgery seem to be unsuitable for nowadays rectal cancer management. BMC surg 22:162PubMedPubMedCentralCrossRef

16.

Schwandner O, Schiedeck TH, Bruch H (1999) The role of conversion in laparoscopic colorectal surgery: do predictive factors exist? Surg Endosc 13:151–156PubMedCrossRef

17.

Crippa J, Grass F, Achilli P, Mathis KL, Kelley SR, Merchea A, Colibaseanu DT, Larson DW (2020) Risk factors for conversion in laparoscopic and robotic rectal cancer surgery. Br J Surg 107:560–566PubMedCrossRef

18.

Franko J, O’Connell BG, Mehall JR, Harper SG, Nejman JH, Zebley DM, Fassler SA (2006) The influence of prior abdominal operations on conversion and complication rates in laparoscopic colorectal surgery. JSLS 10:169–175PubMedPubMedCentral

19.

Zhang GD, Zhi XT, Zhang JL, Bu GB, Ma G, Wang KL (2015) Preoperative prediction of conversion from laparoscopic rectal resection to open surgery: a clinical study of conversion scoring of laparoscopic rectal resection to open surgery. Int J Colorectal Dis 30:1209–1216PubMedCrossRef

20.

Tekkis PP, Senagore AJ, Delaney CP (2005) Conversion rates in laparoscopic colorectal surgery: a predictive model with, 1253 patients. Surg Endosc 19:47–54PubMedCrossRef

21.

Schlachta CM, Mamazza J, Seshadri PA, Cadeddu MO, Poulin EC (2000) Predicting conversion to open surgery in laparoscopic colorectal resections: a simple clinical model. Surg Endosc 14:1114–1117PubMedCrossRef

22.

Cima RR, Hassan I, Poola VP, Larson DW, Dozois EJ, Larson DR, O’Byrne MM, Huebner M (2010) Failure of institutionally derived predictive models of conversion in laparoscopic colorectal surgery to predict conversion outcomes in an independent data set of 998 laparoscopic colorectal procedures. Ann Surg 251:652–658PubMedCrossRef

23.

Ackerman SJ, Daniel S, Baik R, Liu E, Mehendale S, Tackett S, Hellan M (2018) Comparison of complication and conversion rates between robotic-assisted and laparoscopic rectal resection for rectal cancer: which patients and providers could benefit most from robotic-assisted surgery? J Med Econ 21:254–261PubMedCrossRef

24.

Mori T, Kimura T, Kitajima M (2010) Skill accreditation system for laparoscopic gastroenterologic surgeons in Japan. Minim Invasive Ther Allied Technol 19:18–23PubMedCrossRef

25.

Kimura TMT, Konishi F, Kitajima M (2010) Endoscopic surgical skill qualification system in Japan: five years of experience in the gastrointestinal field. Asian J Endosc Surg 3:66–70CrossRef

26.

Yamakawa TKT, Matsuda T, Konishi F, Bandai Y (2013) Endoscopic Surgical Skill Qualification System (ESSQS) of the Japanese Society of Endoscopic Surgery (JSES). BH Surg 3:6–8

27.

Ichikawa N, Homma S, Yoshida T, Ohno Y, Kawamura H, Kamiizumi Y, Iijima H, Taketomi A (2018) Supervision by a technically qualified surgeon affects the proficiency and safety of laparoscopic colectomy performed by novice surgeons. Surg Endosc 32:436–442PubMedCrossRef

28.

Ichikawa N, Homma S, Yoshida T, Ohno Y, Kawamura H, Wakizaka K, Nakanishi K, Kazui K, Iijima H, Shomura H, Funakoshi T, Nakano S, Taketomi A (2017) Mentor tutoring: an efficient method for teaching laparoscopic colorectal surgical skills in a general hospital. Surg Laparosc Endosc Percutaneous Tech 27:479–484CrossRef

29.

Homma S, Kawamata F, Yoshida T, Ohno Y, Ichikawa N, Shibasaki S, Kawamura H, Takahashi N, Taketomi A (2017) The balance between surgical resident education and patient safety in laparoscopic colorectal surgery: surgical resident’s performance has no negative impact. Surg Laparosc Endosc Percutaneous Tech 27:295–300CrossRef

30.

Ichikawa NHS, Hida K, Akagi T, Kamada Y, Yamaguchi T, Masaaki Ito, Ishida F, Watanabe J, Yamamoto D, Iijima H, Yamaguchi S, Inomata M, Sakai Y, Naitoh T, Taketomi A, EnSSURE study group collaboratives in Jaman Society of Laparoscopic Colorectal Surgery (2022) Impact of endoscopic surgical skill qualification on laparoscopic resections for rectal cancer in Japan: The EnSSURE Study. Ann Surg 3:e160CrossRef

31.

Nishizawa YAT, Inomata M, Katayama H, Mizusawa J, Yamamoto S, Ito M, Masaki T, Watanabe M, Shimada Y, Kitano S (2019) Risk factors for early postoperative complications after D3 dissection for stage II or III colon cancer: supplementary analysis of a multicenter randomized controlled trial in Japan (JCOG0404). Ann Gastroenterol Surg 3:310–317PubMedPubMedCentralCrossRef

32.

Nelson H, Sargent DJ, Wieand HS, Fleshman J, Anvari M, Stryker SJ, Beart RW Jr, Hellinger M, Flanagan R Jr, Peters W, Ota D (2004) A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350:2050–2059PubMedCrossRef

33.

Veldkamp R, Kuhry E, Hop WC, Jeekel J, Kazemier G, Bonjer HJ, Haglind E, Påhlman L, Cuesta MA, Msika S, Morino M, Lacy AM (2005) Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 6:477–484PubMedCrossRef

34.

Allaix ME, Degiuli M, Arezzo A, Arolfo S, Morino M (2013) Does conversion affect short-term and oncologic outcomes after laparoscopy for colorectal cancer? Surg Endosc 27:4596–4607PubMedCrossRef

35.

Scheidbach H, Garlipp B, Oberländer H, Adolf D, Köckerling F, Lippert H (2011) Conversion in laparoscopic colorectal cancer surgery: impact on short- and long-term outcome. J Laparoendosc Adv Surg Tech 21:923–927CrossRef

36.

Biondi A, Grosso G, Mistretta A, Marventano S, Tropea A, Gruttadauria S, Basile F (2014) Predictors of conversion in laparoscopic-assisted colectomy for colorectal cancer and clinical outcomes. Surg Laparosc Endosc Percutaneous Tech 24:e21-26CrossRef

37.

Rottoli M, Stocchi L, Geisler DP, Kiran RP (2012) Laparoscopic colorectal resection for cancer: effects of conversion on long-term oncologic outcomes. Surg Endosc 26:1971–1976PubMedCrossRef

38.

Chan AC, Poon JT, Fan JK, Lo SH, Law WL (2008) Impact of conversion on the long-term outcome in laparoscopic resection of colorectal cancer. Surg Endosc 22:2625–2630PubMedCrossRef

39.

White I, Greenberg R, Itah R, Inbar R, Schneebaum S, Avital S (2011) Impact of conversion on short and long-term outcome in laparoscopic resection of curable colorectal cancer. JSLS 15:182–187PubMedPubMedCentralCrossRef

40.

Bouvet M, Mansfield PF, Skibber JM, Curley SA, Ellis LM, Giacco GG, Madary AR, Ota DM, Feig BW (1998) Clinical, pathologic, and economic parameters of laparoscopic colon resection for cancer. Am J Surg 176:554–558PubMedCrossRef

41.

Rottoli M, Bona S, Rosati R, Elmore U, Bianchi PP, Spinelli A, Bartolucci C, Montorsi M (2009) Laparoscopic rectal resection for cancer: effects of conversion on short-term outcome and survival. Ann Surg Oncol 16:1279–1286PubMedCrossRef

42.

Clancy C, O’Leary DP, Burke JP, Redmond HP, Coffey JC, Kerin MJ, Myers E (2015) A meta-analysis to determine the oncological implications of conversion in laparoscopic colorectal cancer surgery. Colorectal Dis 17:482–490PubMedCrossRef

43.

Vaccaro CA, Rossi GL, Quintana GO, Soriano ER, Vaccarezza H, Rubinstein F (2014) Laparoscopic colorectal resections: a simple predictor model and a stratification risk for conversion to open surgery. Dis Colon Rectum 57:869–874PubMedCrossRef

44.

Akagi Tomonori, Endo Hideki, Inomata Masafumi, Yamamoto Hiroyuki, Mori Toshiyuki, Kojima Kazuyuki, Kuroyanagi Hiroya, Sakai Yoshiharu, Nakajima Kentaro, Shiroshita Hidefumi, Etoh Tsuyoshi, Saida Yoshihisa, Yamamoto Seiichiro, Hasegawa Hirotoshi, Ueno Hideki, Kakeji Yoshihiro, Miyata Hiroaki, Kitagawa Yuko, Watanabe Masahiko (2020) Clinical impact of endoscopic surgical skill qualification system (ESSQS) by Japan Society for Endoscopic Surgery (JSES) for laparoscopic distal gastrectomy and low anterior resection based on the National Clinical Database (NCD) registry. Ann Gastroenterol Surg 4:721–734PubMedPubMedCentralCrossRef

45.

Yamamoto S, Ito M, Okuda J, Fujii S, Yamaguchi S, Yoshimura K, Sugihara K, Watanabe M (2013) Laparoscopic surgery for stage 0/I rectal carcinoma: short-term outcomes of a single-arm phase II trial. Ann Surg 258:283–288PubMedCrossRef

46.

Hida K, Okamura R, Sakai Y, Konishi T, Akagi T, Yamaguchi T, Akiyoshi T, Fukuda M, Yamamoto S, Yamamoto M, Nishigori T, Kawada K, Hasegawa S, Morita S, Watanabe M (2018) Open versus laparoscopic surgery for advanced low rectal cancer: a large, multicenter, propensity score matched cohort study in Japan. Ann Surg 268:318–324PubMedCrossRef

47.

Hinoi T, Kawaguchi Y, Hattori M, Okajima M, Ohdan H, Yamamoto S, Hasegawa H, Horie H, Murata K, Yamaguchi S, Sugihara K, Watanabe M (2015) Laparoscopic versus open surgery for colorectal cancer in elderly patients: a multicenter matched case-control study. Ann Surgical Oncol 22:2040–2050CrossRef

48.

Yamaguchi T, Konishi T, Kinugasa Y, Yamamoto S, Akiyoshi T, Okamura R, Ito M, Nishimura Y, Shiozawa M, Yamaguchi S, Hida K, Sakai Y, Watanabe M (2017) Laparoscopic Versus open lateral lymph node dissection for locally advanced low rectal cancer: a subgroup analysis of a large multicenter cohort study in Japan. Dis Colon Rectum 60:954–964PubMedCrossRef

Title: 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: Koki Goto
Jun Watanabe
Toshiya Nagasaki
Mamoru Uemura
Heita Ozawa
Yohei Kurose
Tomonori Akagi
Nobuki Ichikawa
Hiroaki Iijima
Masafumi Inomata
Akinobu Taketomi
Takeshi Naitoh
EnSSURE study group collaboratives in Japan Society of Laparoscopic Colorectal Surgery
Publication date: 08-03-2024
Publisher: Springer US
Keywords: Laparotomy
Laparotomy
Rectal Cancer
Rectal Cancer
Rectal Extirpation
Rectal Extirpation
Published in: Surgical Endoscopy / Issue 5/2024
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-024-10740-y

Keynote webinar | Spotlight on medication adherence

Springer Medicine

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)

Abstract

Background and aims

Methods

Results

Conclusions

Trial Registration

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background and aims

Methods

Results

Conclusions

Trial Registration

Please log in to get access to this content

Other articles of this Issue 5/2024

Risk factors for diaphragmatic injury in subxiphoid video-assisted thoracoscopic surgery

Society of American Gastrointestinal and Endoscopic Surgeons guidelines development: health equity update to standard operating procedure

Natural history of gastric leiomyoma

Achievement of textbook outcome after hepatectomy combined with thermal ablation for colorectal liver metastases

Reasons for conversions in thoracoscopic repairs of neonatal congenital diaphragmatic hernias: a systematic review

Current trends and barriers to video management and analytics as a tool for surgeon skilling