Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov , NCT03471494 . Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.

Highlights Colonic volvulus represents the leading cause of colonic obstruction in sub-Saharan Africa. The sigmoid colon is the primary site of volvulus while the transverse colon is a rare condition. The synchronous occurrence of a sigmoid colon and transverse colon volvulus is exceptional. The dual location of strangulation makes it a major surgical emergency with a high risk of gangrene and septic shock. The literature concerning its description is sparse and the treatment options are poorly codified.

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Spigelian hernia is a rare form of abdominal wall hernias. We report an unusual case of a strangulated spigelian hernia with necrotic contents of the caecum, appendix and terminal ileum in the elderly. An 84-year-old woman, with a history of eight pregnancies, was admitted for bowel obstruction evolving for 7 days. The computed tomography scan showed a strangulated right spigelian hernia. Surgical exploration with an incision centered on the mass confirmed the diagnosis with extensive necrosis of the caecum, appendix and 10 cm of the terminal ileum. A right hemi-colectomy with an ileo-colic anastomosis was performed. The post-operative course was marked by the death of the patient in intensive care due to multi-visceral failure. The occurrence of strangulation with necrosis of the caecum, appendix and terminal ileum in spigelian hernia is extremely rare. It requires early diagnosis and treatment to reduce post-operative morbidity and mortality.