BackgroundLower endoscopy (LE) is the standard diagnostic modality for lower gastrointestinal bleeding (LGIB). Conversely, computed tomographic angiography (CTA) offers an immediate non-invasive diagnosis visualizing the entire gastrointestinal tract. The aim of this study was to compare these 2 modalities with regards to diagnostic value and bleeding control.MethodsTertiary center retrospective analysis of consecutive patients admitted for LGIB between 2006 and 2012. Comparison of patients with LE vs. CTA as first exam, respectively, with emphasis on diagnostic accuracy and bleeding control.ResultsFinal analysis included 183 patients; 122 (66.7%) had LE first, while 32 (17.5%) had CTA; 29 (15.8%) had neither of both exams. Median time to CTA was shorter compared to LE (3 (IQR = 8.2) vs. 22 (IQR = 36.9) hours, P < 0.001). Active bleeding was identified in 31% with CTA vs. 15% with LE (P = 0.031); a non-actively bleeding source was found by CTA and LE in 22 vs. 31%, respectively (P = 0.305). Bleeding control required endoscopy in 19%, surgery in 14% and embolization in 1.6%, while 66% were treated conservatively. Post-interventional bleeding was mostly controlled by endoscopic therapy (57%). 80% of patients with active bleeding on CTA required surgery.ConclusionsPost-interventional LGIB was effectively addressed by LE. For other causes of LGIB, CTA was efficient, and more available than colonoscopy. Treatment was conservative for most patients. In case of active bleeding, CTA could localize the bleeding source and predict the need for surgery.

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.

NCT01713452 (www.clinicaltrials.gov).

Background Spigelian hernias (SpH) belong to the group of eponymous abdominal wall hernias. Major reasons for diagnostic difficulties are its low incidence reaching maximum 2% of abdominal wall hernias, a specific anatomical localization with intact external oblique aponeurosis covering the hernia sac and non-constant clinical presentation. Methods A literature review was completed to summarize current knowledge on surgical treatment options and results. Results SpH presents a high incarceration risk and therefore should be operated upon even if the patient is asymptomatic. Both laparoscopic and open repair approaches are validated by current guidelines with lesser postoperative complications and shorter hospital stay in favour of minimally invasive surgery, regardless of the technique used. Overall recurrence rate is very low. Conclusion All diagnosed SpH should be planned for elective operation to prevent strangulated hernia and, therefore emergency surgery. Both open and laparoscopic SpH treatment can be safely performed, depending on surgeon’s experience. In most cases, a mesh repair is generally advised.

Transrectal specimen extraction after left colectomy using the circular stapler technique is feasible. A side-to-end anastomosis appears safer than an end-to-end anastomosis. Further studies are needed to explore the potential advantages of this procedure over CL.

<b><i>Introduction:</i></b> According to the Barcelona Clinic Liver Cancer (BCLC) algorithm, transarterial chemoembolization (TACE) is recommended in patients with hepatocellular carcinoma (HCC) of intermediate stage (BCLC-B), whereas partial hepatectomy (PH) is restricted to early stage A. Expanding the indication for PH to intermediate stage remains debated. <b><i>Objective:</i></b> This meta-analysis aimed to analyze short- and long-term outcomes of PH compared to TACE in patients with intermediate-stage HCC. <b><i>Methods:</i></b> A meta-analysis was conducted according to PRISMA guidelines. Trials comparing PH with TACE in patients with intermediate-stage HCC were selected. Only patients of BCLC-B stage were included in the analyses. Primary endpoint was overall survival (OS) and secondary endpoint was 90-day postprocedural mortality. Random-effects models were used to analyze time ratios (TRs). <b><i>Results:</i></b> Seven eligible trials were analyzed, including 1,730 BCLC-B patients undergoing PH (<i>n</i> = 750) or TACE (<i>n</i> = 980). Comparison of OS between PH and TACE determined a pooled TR of 1.91 (95% CI 1.24–2.94; <i>p</i> &#x3c; 0.001). Survival rates at 1-, 3-, and 5-year were 85, 60, and 42% after PH, compared to 73, 60, and 20% after TACE (<i>p</i> &#x3c; 0.001). There was no difference in postprocedural mortality between PH and TACE with rates of 3.7 and 3.4%, respectively (TR 0.95; 95% CI 0.17–5.50; <i>p</i> = 0.879). <b><i>Conclusions:</i></b> In patients with intermediate HCC, PH was associated with increased long-term survival compared to TACE, with comparable postprocedural mortality. These results suggest considering PH as treatment option in intermediate HCC and highlight the urgent need to refine the selection of patients with BCLC-B stage who may benefit from PH.

Background Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non‐steroidal anti‐inflammatory drugs (NSAIDs) for reducing ileus after surgery. Methods A prospective multicentre cohort study was delivered by an international, student‐ and trainee‐led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre‐specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury. Results A total of 4164 patients were included, with a median age of 68 (i.q.r. 57–75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1–3, of whom 1061 (92·0 per cent) received non‐selective cyclo‐oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001). Conclusion NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.

Introduction: Enhanced recovery after surgery (ERAS) pathways proved to reduce complications, length of hospital stay and costs after colorectal surgery. Standardized discharge criteria have been established that are fulfilled after complete medical recovery is achieved. This study aimed to assess the timing of complete medical recovery in relation to the timing of actual discharge, and to assess reasons for prolonged hospital stay within an ERAS pathway. Methods: One hundred fourteen consecutive patients undergoing elective colorectal surgery within an ERAS pathway were included in this prospective analysis. Fulfillment of discharge criteria was assessed daily and reasons for prolonged hospital stay were documented. Results: Thirty percent of patients went home on the day that all discharge criteria were met. Overall, patients were discharged at a median of 2 days (interquartile range 1-3) after fulfillment of discharge criteria. Reasons for delayed discharge were (1) organizational in 20%; (2) patient or surgeon unwilling in 29%; and (3) because the patient was deemed to be discharged too soon distance from the operation in 51%. Conclusion: In this observational study, only 30% of patients were discharged on the day all recovery criteria were met. The main reason for continued hospitalization was surgeon- or patient-related reluctance or ‘precaution'; thus, better and more of general information seems to be necessary.