Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov , NCT04384926 . Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include...

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To support the global restart of elective surgery, data from an international prospective cohort study of 8492 patients (69 countries) was analysed using artificial intelligence (machine learning techniques) to develop a predictive score for mortality in surgical patients with SARS-CoV-2. We found that patient rather than operation factors were the best predictors and used these to create the COVIDsurg Mortality Score (https://covidsurgrisk.app). Our data demonstrates that it is safe to restart a wide range of surgical services for selected patients.

Necrotising fasciitis (NF) is a severe infection of the subcutaneous tissue and fascia that can rapidly lead to sepsis and shock with high mortality rates. Its initial signs are often non-specific making it difficult for an early diagnosis to be reached. Nevertheless it is of the utmost importance to begin proper treatment including wide surgical debridement as soon as possible in order to avoid death. We present the case of a patient with NF of the thoracic wall which is a rare location for this disease but often associated with worse prognosis. Even though he progressed to septic shock within less than 24 hours of its presentation, due to early surgical management, aggressive resuscitation and intensive care support, he reached a favourable outcome. After three surgical revisions and 2 weeks in an intensive care unit, the patient was discharged from hospital 35 days after admission.

Introduction: The safety and feasibility of laparoscopic two-stage hepatectomy (TSH) for bilobar colorectal liver metastases (CRLM) is poorly evaluated. Method: Eighty patients who underwent complete TSH for bilobar CRLM between 2007 and 2017 at three centers (Hôpital Pitié-Salpêtrière, Institut Mutualiste Montsouris, Hôpital Saint-Antoine) were enrolled. Laparoscopic and open TSH were compared after propensity score matching (PSM). Results: Laparoscopic TSH was performed in 35 patients, while open TSH was performed in 45 patients. After PSM, 23 laparoscopic and 23 open patients had similar preoperative and oncological characteristics.For the first stage, a laparoscopic approach showed a trend toward less complications (13.0% vs. 34.8%; P = 0.084) and significantly shorter hospital stay (4 vs. 7 days; P = 0.004). The interval period was comparable between the groups (2.3 vs. 2.5 months; P = 0.750). For the second stage, a laparoscopic approach was associated with a trend toward less liverspecific complications (26.1% vs. 52.2%; P = 0.070), significantly shorter hospital stay (8.5 vs. 14 days; P = 0.008) and earlier administration of adjuvant chemotherapy (1.6 vs. 2.0 months; P = 0.039). Overall survival (OS) and disease-free survival (DFS) rates were comparable between the groups (3-year OS: 95.7% vs. 87.5%; P = 0.889; 3-year DFS: 22.1% vs. 8.1%; P = 0.373). Repeat hepatectomy for intrahepatic recurrence was more frequently performed in the laparoscopic TSH group (57.1% vs. 11.1%; P = 0.049). Conclusions: Laparoscopic TSH is safe and feasible for bilobar CRLM in selected patients with comparable oncological outcomes to open TSH.

a difficult excision (extended left hepatectomy, arterial reconstructions). Results: The analysis involved 74 patients, of median age 66, including 40Y and 34X. In group Y, 97% received a pre-operative work-out (left biliary drainage / right portal embolization). Excision was possible in 100% of cases (80% R0) with portal resection in 16 cases. No left arterial invasion. 90 days morbidity (Clavien-Dindo3) was 55%, mortality was 10%. In group X, excision was possible in 27 cases (80% vs 100% (X / Y), p = 0.003). 71% of R0 (p>0,05) were found. Vascular invasion required portal resection-reconstruction in 9 cases (p>0,05), arterial in 6 cases (p = 0.05). 90 days morbidity was 48%, mortality was 11% (p>0,05). 4 yrs overall and recurrence-free survival rates were respectively 55.7% (Y) vs. 49.7% (X) and 39.4% (Y) vs.37.3% (X) (p>0,05). Conclusion: The XY classification is reliable for predicting the absence of left arterial invasion and a 100% resection rate of Y types.

Myeloid sarcoma (MS) is a rare condition that most commonly occurs in the setting of acute myeloidleukaemia (AML) or other chronic myeloproliferative disorders. It presents as an abnormal growth that can develop anywhere in the human body, and its clinical manifestations are often non-specific.We present the case of a patient admitted to the emergency room with bowel obstruction. After careful clinical assessment, she underwent a right hemicolectomy. After a thorough examination of the surgical pathology specimen, including testing a wide array of immunohistochemical markers, the patient was timely diagnosed with MS, allowing for the implementation of the appropriate treatment to achieve complete remission. This is crucial, since non-leukaemic patients with untreated MS always progress to AML, and have a better prognosis if adequate therapy is implemented early. Our patient is now in the second postoperative year and shows no signs of relapse.

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