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.

BackgroundPerineal wound complications are often encountered following abdominoperineal resection (APR). Filling of the pelvic space by omentoplasty (OP) might prevent these complications, but there is scant evidence to support its routine application.ObjectiveThe aim of this study was to evaluate the impact of OP on perineal wound complications.MethodsAll patients undergoing APR with primary perineal closure (PPC) for non-locally advanced rectal cancer in 71 Dutch centers in 2011 were selected from a cross-sectional snapshot study. Outcomes were compared between PPC with or without OP, which was based on variability in practice among surgeons.ResultsOf 639 patients who underwent APR for rectal cancer, 477 had a non-locally advanced tumor and PPC was performed. Of those, 172 (36%) underwent OP. Patients with OP statistically more often underwent an extralevator approach (32% vs. 14%). Median follow-up was 41 months (interquartile range 22–47). There were no significant differences with or without OP in terms of non-healing of the perineal wound at 30 days (47% vs. 48%), non-healing at the end of follow-up (9% vs. 5%), pelvic abscess (12% vs. 13%) or re-intervention for ileus (5% vs. 3%). Perineal hernia developed significantly more often after OP (13% vs. 7%), also by multivariable analysis (odds ratio 2.61, 95% confidence interval 1.271–5.364; p = 0.009).ConclusionsIn contrast to previous assumptions, OP after APR with PPC appeared not to improve perineal wound healing and seemed to increase the occurrence of perineal hernia. These findings question the routine use of OP for primary filling of the pelvic space.Electronic supplementary materialThe online version of this article (10.1245/s10434-017-6273-9) contains supplementary material, which is available to authorized users.

Aim There is little evidence concerning the optimal surgical technique for the repair of perineal hernia. This study aimed to report on the evolution of a technique for repair of perineal hernia by analysing the experience in a tertiary referral centre. Method This was a retrospective review of consecutive patients who underwent perineal hernia repair after abdominoperineal excision in a tertiary referral centre. The main study end‐points were rate of recurrent perineal hernia, perineal wound complications and related re‐intervention. Results Thirty‐four patients were included: in 18 patients a biological mesh was used followed by 16 patients who underwent synthetic mesh repair. Postoperative perineal wound infection occurred in two patients (11%) after biological mesh repair compared with four (25%) after synthetic mesh repair (P = 0.387). None of the meshes were explanted. Recurrent perineal hernia following biological mesh was found in 7 of 18 patients (39%) after a median of 33 months. The recurrence rate with a synthetic mesh was 5 of 16 patients (31%) after a median of 17 months (P = 0.642). Re‐repair was performed in four (22%) and two patients (13%), respectively (P = 0.660). Eight patients required a transposition flap reconstruction to close the perineum over the mesh, and no recurrent hernias were observed in this subgroup (P = 0.030). No mesh‐related small bowel complications occurred. Conclusion Recurrence rates after perineal hernia repair following abdominoperineal excision were high, and did not seem to be related to the type of mesh. If a transposition flap was added to the mesh repair no recurrences were observed, but this finding needs confirmation in larger studies.

Level II, prognostic study.

The objective of this systematic review and meta-analysis was to examine the effects of omentoplasty on pelviperineal morbidity following abdominoperineal resection (APR) in patients with cancer. Background: Recent studies have questioned the use of omentoplasty for the prevention of perineal wound complications. Methods: A systematic review of published literature since 2000 on the use of omentoplasty during APR for cancer was undertaken. The authors were requested to share their source patient data. Meta-analyses were conducted using a random-effects model. Results: Fourteen studies comprising 1894 patients (n ¼ 839 omentoplasty) were included. The majority had APR for rectal cancer (87%). Omentoplasty was not significantly associated with the risk of presacral abscess formation in the overall population (RR 1.11; 95% CI 0.79-1.56), nor in planned subgroup analysis (n ¼ 758) of APR with primary perineal closure for nonlocally advanced rectal cancer (RR 1.06; 95% CI 0.68-1.64). No overall differences were found for complicated perineal wound healing within 30 days (RR 1.30; 95% CI 0.92-1.82), chronic perineal sinus (RR 1.08; 95% CI 0.53-2.20), and pelviperineal complication necessitating reoperation (RR 1.06; 95% CI 0.80-1.42) as well. An increased risk of developing a perineal hernia was found for patients submitted to omentoplasty (RR 1.85; 95% CI 1.26-2.72). Complications related to the omentoplasty were reported in 4.6% (95% CI 2.5%-8.6%). Conclusions: This meta-analysis revealed no beneficial effect of omentoplasty on presacral abscess formation and perineal wound healing after APR, while it increases the likelihood of developing a perineal hernia. These findings do not support the routine use of omentoplasty in APR for cancer.

BACKGROUND: Abdominoperineal resection is associated with a high incidence of perineal complications, and whether this is reduced by an omentoplasty is still unclear. OBJECTIVE: This study aimed to investigate the impact of omentoplasty on pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer. DESIGN: This was a retrospective comparative cohort study using propensity score analyses to reduce potential confounding. SETTING: The study was undertaken in 2 teaching hospitals and 1 university hospital. PATIENTS: Patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2017 were included. MAIN OUTCOME MEASURES: The main end points were primary perineal wound healing at 30 days and overall and specific pelviperineal morbidity until the end of the study period. RESULTS: Among 254 included patients, 106 had an omentoplasty. The primary perineal wound healing rate at 30 days was similar for omentoplasty and no omentoplasty (65% vs 60%; p = 0.422), also after adjusting for potential confounding by propensity score analysis (OR, 0.89; 95% CI, 0.45–1.75). Being free from any pelviperineal complication at 6 months (75% vs 79%; p = 0.492), absence of any pelviperineal morbidity until 1 year (54% vs 49%; p = 0.484), and incidence of persistent perineal sinus (6% vs 10%; p = 0.256) were also similar in both groups. The unadjusted higher perineal hernia rate after omentoplasty (18% vs 7%; p = 0.011) did not remain statistically significant after regression analysis including the propensity score (OR, 1.34; 95% CI, 0.46–3.88). Complications related to the omentoplasty itself were observed in 8 patients, of whom 6 required reoperation. LIMITATIONS: This study was limited by the retrospective and nonrandomized design causing some heterogeneity between the 2 cohorts. CONCLUSION: In this multicenter study using propensity score analyses, the use of omentoplasty did not lower the incidence or the duration of pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer, and omentoplasty itself was associated with a risk of reoperation. See Video Abstract at http://links.lww.com/DCR/A918.

Background Some Internet sites have programs that attempt to help patients find their diagnosis based on symptoms. This study tested the null hypothesis that there are no factors associated with correspondence between online diagnosis and the hand surgeon's diagnosis in an outpatient hand and upper extremity surgeons' office. Methods Eighty-six outpatients were prospectively enrolled and used WebMD® symptom checker to guess their diagnosis. We collected demographic information, hours spent on the Internet per week, and the following questionnaires: Pain Catastrophizing Scale (PCS) and Center of Epidemiologic Studies Depression scale (C-ESD).Results Thirty-three percent of online diagnoses matched the final diagnosis of the hand surgeon. Factors associated with an online diagnosis corresponding to the hand surgeon's diagnosis included sex (women) and patients who studied their symptoms online prior to the visit. The best multivariable model included sex, more years of education, and prior use of the Internet to research their medical condition and explained 15 % of the variation in correspondence of diagnosis.Conclusions The majority of online diagnoses for hand and upper extremity conditions do not correspond with the diagnosis of the treating hand surgeon. Psychological factors do not influence the correspondence of online diagnosis with the hand surgeon's diagnosis.Level of Evidence: Prognostic, level II

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