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.

The meta-analysis showed that LLR is beneficial in terms of overall morbidity and non-procedure-specific complications. That being said, these results are based on non-randomized trials. For these reasons, we are calling for randomization in upcoming studies. Systematic review registration: PROSPERO registration number CRD42018084576.

BackgroundTransanal total mesorectal excision (TaTME) is emerging as a novel alternative to laparoscopic total mesorectal excision (LaTME). The aim of this study was to compare clinical and pathological results from these two techniques in patients undergoing rectal resections because of low rectal cancer.Materials and methodsThirty-five patients undergoing TaTME were matched with 35 patients operated on using LaTME. Composite primary endpoint (complete TME, negative circumferential resection margin [pCRM], and distal resection margin [pDRM]) was used to assess pathological quality specimens. Secondary outcomes included operative and postoperative parameters (operative time, total blood loss, postoperative morbidity, length of stay, 30-day mortality).ResultsComposite primary endpoint was achieved by 85% of subjects in the TaTME group and 82% of subjects in the LaTME group (P=0.66). Mean pCRM was 1.1±1.29 vs 0.99±0.78 mm (P=0.25). Distal pDRM was 1.57±0.92 and 1.98±1.22 cm (P=0.15). In the TaTME and LaTME groups, respectively, complete mesorectal excision was achieved in 89% and 83% of subjects, while excision was nearly complete for the remaining 11% and 17% (P=0.23).ConclusionTaTME appears to be a noninferior alternative to laparoscopic surgery. TaTME allows for quality retrieval of surgical specimens with comparable clinical outcomes with LaTME.

Introduction Enhanced recovery after surgery (ERAS) pathways have been proven to enhance postoperative recovery, reduce morbidity, and reduce length of hospital stay after colorectal cancer surgery. However, despite the benefits of the ERAS program on short-term results, little is known about its impact on long-term results.Objective The aim of the study was to determine the association between adherence to the ERAS protocol and longterm survival after laparoscopic colorectal resection for non-metastatic cancer. Material and Methodology Between 2013 and 2016, 350 patients underwent laparoscopic colorectal cancer resection in the 2nd Department of General Surgery, Jagiellonian University Medical College, and were enrolled for further analysis. The relationship between the rate of compliance with the ERAS protocol and 3-year survival was analyzed according to the Kaplan-Meier method with log-rank tests. Patients were divided into two groups according to their degree of adherence to the ERAS interventions: Group 1 (109 patients), \ 80% adherence, and Group 2 (241 patients), C 80% adherence. The primary outcome was overall 3-year survival. The secondary outcomes were postoperative complications, length of hospital stay, and recovery parameters. Results The groups were similar in terms of demographics and surgical parameters. The median compliance to ERAS interventions was 85.2%. The Cox proportional model showed that AJCC III (HR 3.28, 95% CI 1.61-6.59, p = 0.0021), postoperative complications (HR 2.63, 95% CI 1.19-5.52, p = 0.0161), and compliance with ERAS protocol \ 80% (HR 3.38, 95% CI 2.23-5.21, p = 0.0102) were independent predictors for poor prognosis. Additionally, analysis revealed that adherence to the ERAS protocol in Group 2 with C 80% adherence was associated with a significantly shorter length of hospital stay (6 vs. 4 days, p \ 0.0001), a lower rate of postoperative complications (44.7% vs. 23.3%, p \ 0.0001), and improved functional recovery parameters: tolerance of oral diet (53.4% vs. 81.5%, p \ 0.0001) and mobilization (77.7% vs. 96.1%, p \ 0.0001) on the first postoperative day. Conclusions and RelevanceThis study reports an association between adherence to the ERAS protocol and longterm survival after laparoscopic colorectal resection for non-metastatic cancer. Lower adherence to the protocol, independent from stage of cancer and postoperative complications, was an independent risk factors for poorer survival rates. & Michał Pędziwiatr Hypertension, n (%) 53 (48.6%) 119 (49.4%) 0. 8961 Diabetes, n (%) 23 (21.1%) 38 (15.8%) 0. 2232 Pulmonary disease, n (%) 11 (10.1%) 20 (8.3%) 0. 5846 Renal disease, n (%) 8 (7.3%) 14 (5.8%) 0. 5849 Formation of stoma 23 (21.1%) 66 (27.4%) 0. 2112 Median operative time, min. (IQR) 180 (140-240) 190 (160-230) 0.7148 Median intraoperative blood loss, mL (IQR) 100 (50-100) 100 (50-150) 0.7797 Conversion, n (%) 5 (4.6%) 7 (2.9%) 0. 4231 Need for blood transfusion, n (%) 9 (8.3%) 21 (8.7%) 0.8876 Colon, n (%) 71 (65.1%) 155 (64.3%) 0.8816 Rectum, n (%) 38 (34.9%) 86 (35...

Introduction: Transanal total mesorectal excision (TaTME) has been recently proposed to overcome the difficulties of the standard TME approach, allowing better visualization and dissection of the mesorectal fascia. Although TaTME seems very promising, the evidence and body of knowledge on achieving proficiency in performing it are still sparse. Aim: To evaluate the learning curve of TaTME based on a single centre's experience. Material and methods: Consecutive patients undergoing TaTME since 2014 in a tertiary referral department were included in the study. All procedures were performed by one experienced surgeon. CUSUM curve analyses were performed to evaluate learning curves. Results: Sixty-six patients underwent TaTME. After analysis of postoperative morbidity rate, intraoperative adverse effects and operative time, we estimated that 40 cases are needed to achieve TaTME proficiency. Subsequently, patients were divided into two groups: before (40 patients) and after overcoming the learning curve (26 patients). Group 1 had higher readmission (p = 0.041) and complication rates (p = 0.019). There were no statistically significant differences in terms of intraoperative adverse effects, length of stay or pathological quality of the specimen. Conclusions: Transanal total mesorectal excision is a promising yet technically demanding procedure and requires at least 40 cases to complete the learning curve. More data are needed to introduce it as a standard procedure for low rectal cancer treatment.

Most of the studies concerning enhanced recovery after surgery (ERAS) protocols in colorectal surgery include heterogeneous groups of patients undergoing open or laparoscopic surgery, both due to colonic and rectal cancer, thus creating a potential bias. The data investigating the differences between patients operated for either colonic or rectal cancer are sparse. The aim of the study was to compare short-term outcomes of laparoscopic surgery for colonic and rectal cancer with ERAS protocol. The analysis included consecutive prospectively registered patients operated for a colorectal cancer between January 2012 and September 2015. Patients were divided into two groups (colon vs. rectum). The measured outcomes were: length of stay (LOS), complication rate, readmission rate, compliance with ERAS protocol elements and recovery parameters (tolerance of early oral diet, mobilization and time to first flatus). Group 1 (colon) consisted of 150 patients and Group 2 (rectum) of 82 patients. Patients in Group 1 (150 patients) were discharged home earlier than in Group 2 (82 patients)—median LOS 4 versus 5 days, respectively. There was no statistical difference in complication rate (27.3 vs. 36.6 %) and readmissions (7.3 vs. 6.1 %). Compliance with the protocol was 86.9 and 82.6 %, respectively. However, in Group 1, the following procedures were used less frequently: bowel preparation (24 vs. 78.3 %) and postoperative drainage (23.3 vs. 71.0 %). There were no differences in recovery parameters between the groups. Univariate logistic regression showed that the type of surgery, drainage and stoma creation significantly prolonged LOS. In a multivariate logistic regression model, only a bowel preparation and drainage were shown to be significant. Although functional recovery and high compliance with ERAS protocol are possible irrespective of the type of surgery, laparoscopic rectal resections are associated with a longer LOS.

We believe that CHO-loading is not clinically justified in case of laparoscopic cholecystectomy. No effect on the levels of glucose, insulin resistance and cortisol was observed. Even though such procedure is safe, in our opinion there is no clinical benefit from CHO-loading prior to laparoscopic cholecystectomy.

Background Aim of this study was to evaluate functional outcomes of transanal total mesorectal excision (TaTME) in comparison to conventional laparoscopic approach (LaTME) in terms of low anterior resection syndrome (LARS). Methods Forty-six patients who underwent total mesorectal excision for low rectal cancer between 2013 and 2017 were enrolled. Primary outcome was the severity of faecal incontinence, assessed both before the treatment and 6 months after ileostomy reversal. LARS score and Jorge-Wexner scale were utilized to analyze its severity. Results Twenty (87%) from TaTME and 21 (91%) from LaTME group developed LARS postoperatively. There were no significant differences between groups in terms of LARS occurrence ( p = 0.63) and severity. The median Wexner score was comparable in both groups (8 [IQR: 4–12] vs 7 [3–11], p = 0.83). Univariate analysis revealed that postoperative complications were a risk factor for LARS development ( p = 0.02). Perioperative outcomes, including operative time, blood loss and intraoperative adverse events did not differ significantly between groups either. Five TaTME patients developed postoperative complications, while there were morbidity 6 cases in LaTME group. Quality of mesorectal excision was comparable with 20 and 19 complete cases in TaTME and LaTME groups, respectively. Conclusions TaTME provided comparable outcomes in terms of functional outcomes in comparison to LaTME for total mesorectal excision in low rectal cancers. Having said that, LARS prevalence is still high and requires further evaluation of the technique.