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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Highlights Pericecal hernia is a rare type of internal hernias accounting for 0.1–6.6% of all internal hernias. Pericecal hernia is rare in pediatric patients, clinical presentation depends on the degree of bowel obstruction. Keeping in mind the radiation risks. CT scan is the key for internal hernia diagnosis and management. High index of clinical suspicion and early intervention saves the patient from extensive bowel resection.

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IntroductionAppendiceal injuries following a blunt abdominal trauma are rare. Upon literature review, several cases have been reported to develop appendicitis following blunt abdominal trauma, but total transection of the appendix is extremely rare.Case presentationOur case involves a 24-year-old male restrained driver who was involved in a motor vehicle accident. He had bruising corresponding to the pattern of the seatbelt, the ‘seatbelt sign’, on admission. On his second day of admission, he was found to have a rigid abdomen. On exploratory laparotomy, the patient had a completely transected appendix with a 10 × 10 cm piece of transected omentum lying in the pelvic cavity.DiscussionLiterature suggests that seat belts may play a role in the mechanism of injury leading to transection.ConclusionSince the introduction of seatbelt in the 1970s, fatalities from road traffic accidents have fallen by up to 60%. However, the seat belt itself is associated with a unique injury profile, including intestinal tears, perforations, and transections, collectively termed “the seatbelt syndrome”. Seat belt syndrome injuries may sometimes have a delayed presentation, thus repeated abdominal examination is recommended even if the patient is initially stable. Appendiceal transection is rare but may occur. A thorough inspection of the abdominal soft tissue to look for accompanying injuries is important if case an exploratory laparotomy is warranted.