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.

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Splenic artery aneurysms are rare clinical entities that carry the risk of rupture and fatal hemorrhage. Due to the availability of advanced imaging techniques, they are now being found more frequently and identified earlier. Historically, the surgical approach to their management has consisted of laparotomy with resection of the aneurysm and a possible splenectomy. Recently, angiographic interventions and laparoscopic exclusion of splenic artery aneurysm has been shown to provide adequate therapy without the morbidity associated with open aneurysmectomy and splenectomy. In patients with previous abdominal surgery, a planned hand-assisted approach may be needed. We present the cases of two patients with splenic artery aneurysms who were successfully managed laparoscopically. The hand-assisted approach was needed in our second patient, who had a history of gastric bypass surgery. Both patients had an uneventful postoperative course and were discharged home on postoperative day one.

Symptomatic perineal hernia is a rare complication after abdominoperineal resection. Various approaches to surgical repair have been described, including transabdominal, transperineal, and combined abdominoperineal repairs. In this report, we present a laparoscopic approach for repairing a perineal hernia that developed 10 months after laparoscopy-assisted abdominoperineal resection for a recurrent squamous cell carcinoma of the anal canal. To the best of our knowledge, this is the first report of a laparoscopic repair of perineal hernia.