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Published on: April 19, 2022
Association of the IWATE Difficulty Score With Conversion to Open Surgery and Perioperative Outcomes After
Lai Thien Vo1, Kim Hoai Nguyen1, Ho Tran2,3
1Department of Liver Tumor, Binh Dan Hospital, Ho Chi Minh City, Vietnam.
Introduction:
This study evaluated the association of the IWATE difficulty score with conversion to open surgery and perioperative outcomes after laparoscopic liver resection and explored the association between cirrhosis and conversion.
Methods:
This single-center retrospective cohort included 84 consecutive patients who underwent planned laparoscopic liver resection in Vietnam between January 2024 and March 2026. Patients were classified into low/intermediate and advanced/expert IWATE groups. The primary outcome was conversion to open surgery. Secondary outcomes included operative time, intraoperative blood loss, perioperative blood transfusion, 90-day postoperative complications, and postoperative length of hospital stay. Discrimination for conversion was assessed using receiver operating characteristic analysis. Exploratory logistic regression analyses evaluated the associations of IWATE difficulty and cirrhosis with conversion.
Results:
Fifty-three patients had low/intermediate and 31 had advanced/expert difficulty. Conversion occurred in 4 of 53 patients (7.5%) and 12 of 31 patients (38.7%), respectively (p = 0.001). Advanced/expert difficulty remained associated with conversion after adjustment for overall cirrhosis status (adjusted odds ratio, 6.30; 95% confidence interval, 1.54-25.79; p = 0.010). Overall cirrhosis was also associated with conversion (adjusted odds ratio, 13.29; 95% confidence interval, 3.32-53.19; p < 0.001). A sensitivity analysis restricted to cirrhosis documented before surgery showed similar exploratory associations, although confidence intervals were wide. The advanced/expert group had longer operative time, greater intraoperative blood loss, more 90-day postoperative complications, and longer postoperative hospital stay. The area under the receiver operating characteristic curve was 0.834 (95% confidence interval, 0.717-0.951); an exploratory cutoff of ≥ 8 provided 68.8% sensitivity and 85.3% specificity. Of the 16 conversions, 11 were bleeding-related and five were non-bleeding-related.
Conclusion:
Higher IWATE difficulty was associated with conversion to open surgery and worse perioperative outcomes. Cirrhosis showed an exploratory association with conversion after adjustment for IWATE difficulty, but these findings require confirmation in larger cohorts.
