Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. National Institute for Health and Care Research.

Background and objective: Rectus sheath haematoma (RSH) is an uncommon condition that may vary from contained haematoma to life-threatening bleeding. Timely diagnosis and treatment is crucial in this patient population. The aim of the current study was to investigate the results of the different RSH treatment strategies among patients admitted to a surgery department. Materials and methods: A retrospective analysis of 29 patients treated for RSH in surgery departments of two medical centres from 1 January 2007 to 30 September 2017 was conducted. The patient’s age, sex, ASA (American Society of Anesthesiologists; physical status classification system), use of anticoagulants, cause of haematoma, radiological data, vital signs, blood investigations, and type of treatment were extracted. The results were analysed according to the type of treatment. Results: The patients’ mean age was 67.6 ± 14.3 years, and the mean duration of in-hospital stay was 10.7 ± 6.7 days. All patients were on anticoagulant treatment, and 82.8% of them had spontaneous haematoma. Nine patients (31%) needed transfusion of packed red blood cells with an average of 2.6 units (range: 1–4). Five patients (17.2%) presented with symptoms and signs of hypovolemic shock, and four of them underwent embolisation. Embolisation was successful in all cases. Open surgery was performed in 6 patients, 8 patients underwent percutaneous drainage, and 10 patients were treated conservatively. Two patients (6.7%) died in our series. Both of these patients had type III RSH. Patients in the conservatively treated group had the shortest hospital stay. There were no readmissions due to repeated haematoma or infection. Conclusions: Embolisation of epigastric arteries is a useful tool to stop bleeding into RSH in patients with unstable haemodynamics. Conservative treatment is comparable to ultrasound (US) drainage of RSH but results in a shorter hospital stay. Type III RSH is associated with a higher death rate.

Background and Objectives: The prevalence of GERD is increasing among individuals with obesity, and RYGB is an effective procedure to control GERD and obesity. However, some patients continue to have GERD after RYGB. The aim of this study was to investigate the prevalence and the risk factors for GERD after RYGB. Material and Methods: This prospective study included 180 RYGB patients followed for an average of 12.2 (0.6) years. In total, 126 (70%) patients agreed to participate and provided data on their weight, GERD symptoms, and filled the GERD-HRQL, TFEQ-18, and GSRS questionnaires. Results: The average age before surgery was 42.7 (10.5) years, and BMI was 45.2 (6.4) kg/m². Moreover, 128 (71.1%) were females, and preoperative GERD was diagnosed in 74 (41.1%) patients. At the 12-year follow-up, the mean %EBMIL and %TWL was 60.37 and 25.73, respectively. The median %WR was 18.0 (39.0). Postoperative GERD was present in 30 (23.8%) patients, of whom 12 (40%) continued to have GERD symptoms and 18 (60%) developed de novo GERD. The GERD-HRQL score significantly decreased from 3.0 (9.0) at baseline to 2.0 (5.0) (p = 0.028) at 12 years. GSRS Diarrhea and Indigestion scores increased significantly from 1.33 (0.67) to 1.5 (2.42) (p < 0.001) and from 2.0 (1.25) to 2.25 (1.25) (p < 0.001), respectively. No change in the cognitive restraint score was observed. Uncontrolled eating and emotional eating scores decreased from 51.85 (22.22) to 40.74 (33.33) (p < 0.001) and from 44.44 (44.44) to 33.33 (22.22) (p < 0.001), respectively. In the multivariate analysis, %WR > 11 (OR = 3.22, p = 0.029) and GSRS Diarrhea score (OR = 3.21, p = 0.027) were significant predictors of GERD 12 years after RYGB. Conclusions: RYGB was an effective procedure to control GERD; however, 23.8% had persistent or de novo GERD after 12 years. The independent risk factors associated with GERD after RYGB were weight regain and GSRS Diarrhea score.

Introduction: Median arcuate ligament syndrome (MALS) is a compressed celiac artery syndrome, also known as Dunbar syndrome. MALS is a clinically rare syndrome and is usually a diagnosis of exclusion. Diagnosis is a difficult task. Surgery is the treatment of choice, and laparoscopic surgery has promising results. Case presentation: A 40-year-old female with no comorbidities presented to her primary physician complaining of chronic abdominal pain, appetite loss, pain after eating, weight loss for about 5 years. Physical examination results were unremarkable. The abdomen/pelvis computed tomography angiography (CTA) was performed and 50% celiac artery stenosis was found. Due to inadequate symptom control and otherwise unremarkable workup, laparoscopic median arcuate ligament release was scheduled. The publication has been reported in line with the SCARE criteria [13]. Clinical discussion: The etiology and pathophysiology of Dunbar syndrome are incompletely understood but may be related to both ischemic and neuropathic mechanisms. There are theories that MALS is associated with either a neurogenic or vascular origin for the clinical features, but objective evidence to support these theories is lacking. If MALS is suspected, abdominal/pelvic CTA can be used to verify the location of the celiac trunk. Despite the controversy regarding the pathophysiology, most patients with MALS have a good response to laparoscopic decompression. Conclusions: MALS is a rare and incompletely understood syndrome. Laparoscopic median arcuate ligament release and transection of the celiac plexus is an effective treatment for MALS. Highlights:

Background and Objectives: Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome, is a vascular compression disorder. Over time, laparoscopy has become increasingly important in the treatment of MALS, gradually replacing open surgical reconstruction as the preferred first-line approach in most cases. We present nine years of experience managing patients with MALS, aiming to contribute to the evidence supporting this long-debated condition. Materials and Methods: A single-center prospective observational cohort study analysis was conducted. CT angiography was used to confirm the diagnosis of MALS in all patients. All surgical patients completed the Gastrointestinal Quality of Life Index (GIQLI) and Gastrointestinal Symptom Rating Scale (GSRS) questionnaires preoperatively and postoperatively. All the patients underwent laparoscopic decompression. Postoperative follow-up visits were scheduled at one month and three years postoperatively. Results: During the study period, 37 patients were diagnosed with MALS, of whom 11 (29.7%) were symptomatic and underwent laparoscopic decompression. The operated cohort consisted of nine women and two men (mean age 56.7 ± 10.7 years). All patients reported postprandial epigastric pain, and 63.6% experienced weight loss. Laparoscopic decompression was successfully completed in all cases without intraoperative complications. Two patients had stenting after surgery, and in two, prior to surgery. The mean operative time was 103 ± 54 min, and the mean hospital stay was 4.2 ± 2.2 days. At 3-year follow-up, 36.4% of patients reported recurrent symptoms associated with recurrent celiac trunk stenosis on CT angiography. Overall, the patients had less indigestion and less pain; however, the differences did not reach a statistically significant level. Conclusions: Laparoscopic decompression of the median arcuate ligament is a feasible and safe treatment for carefully selected patients with symptomatic MALS, offering durable symptom relief in most cases with minimal morbidity.

DOI: 10.20452/wiitm.2024.17889, Published online: July 31, 2024, Authors: Mindaugas Kiudelis¹, Matas Pažusis¹, Linas Venclauskas¹, Eglė Kubiliūtė¹, Algirda Venclauskienė²