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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Giant bladder stone is a rare phenomenon. Surgical treatment which involves open vesicolithotomy and delivery of the bladder stone is usually straightforward. Herein, we report a 69-year-old gentleman with a neglected giant bladder stone complicated by obstructive uropathy and acute renal failure. After medical condition was stabilized, he underwent open vesicolithotomy. At surgery, delivery of the giant bladder stone was difficult both manually and with stone forceps. The stone was later delivered successfully by Wrigley’s obstetrics forceps. We report this case to highlight the rare cause of acute renal failure and the use of obstetrics forceps in the management of giant bladder stones.

Megarectum rarely occur in adults. Rectal innervation abnormality or rectal muscle dysfunction could be the underlying pathophysiology, but there are cases where no specific cause is found. Only a handful of cases of megarectum in pregnancy were reported in the literature. Raised progesterone and reduced motilin level during pregnancy may affect bowel motility and predispose pregnant patients to this unusual condition. Clinical presentation ranges from bowel symptoms e.g. chronic constipation, nausea, vomiting and abdominal pain to dysfunctional labour including labour dystocia and obstructed labour. We hereby present a 23 year old lady in early pregnancy who presented with coital penetration failure due to megarectum. We wish to discuss the impact, outcome and management of this rare condition in pregnancy.