BACKGROUND Minimally invasive surgery is rapidly expanding globally, yet there is insufficient knowledge of how to scale this technology safely and equitably across diverse health systems. We aimed to identify health-system factors associated with safe implementation of minimally invasive surgery globally, using minimally invasive cholecystectomy as a tracer procedure. METHODS We conducted a multicentre, prospective cohort study of consecutive adults undergoing cholecystectomy between July 31 and Nov 19, 2023, in 1218 hospitals across 109 countries. Data were collected by more than 10 000 health-care workers using a core measurement set mapped to the WHO Health System Building Blocks and the Global Patient Safety Action Plan. The primary outcome was 30-day procedure-specific complications, with multilevel logistic regression used to examine associations between health-system features and patient outcomes. This study is registered on ClinicalTrials.gov (NCT06223061). FINDINGS Among 52 187 included patients, the adjusted procedure-specific complication rate varied 40-fold between hospitals, from 0·3% in the lowest risk quintile to 12·1% in the highest risk quintile. Despite large structural differences across income groups in access to minimally invasive surgery, diagnostics, and emergency services, country income level was not independently associated with complication rates (adjusted odds ratio [OR] 0·81 [95% CI 0·59-1·10] for upper-middle income vs high income and 0·99 [0·70-1·39] for lower-middle income or low income vs high income). Three modifiable hospital-level factors were strongly associated with safer outcomes: establishment of local simulation-based training facilities (adjusted OR 0·78 [0·71-0·86]; p<0·0001), adoption of intraoperative safety and communication strategies (0·87 [0·79-0·96]; p=0·0046), and on-site CT diagnostics (0·79 [0·65-0·97]; p=0·0220). Training facilities showed the greatest benefit in hospitals with limited infrastructure and an inexperienced workforce: the number needed to treat to prevent a procedure-specific complication was 21 (95% CI 14-35; p<0·0001). INTERPRETATION Safe implementation of minimally invasive surgery varies widely worldwide but is not defined by national income level; differences in outcomes reflect the ability of health systems to adopt and safely deploy new surgical techniques. We identified for the first time that the presence of local simulation-based training facilities is independently associated with improved patient outcomes. Simulation appears to be fundamental to the safe delivery of minimally invasive surgery, particularly in resource-constrained settings. Together with safety systems and diagnostic capacity, these findings offer actionable targets for health systems seeking to equitably scale up essential surgical technologies. FUNDING NIHR Global Health Research Unit and Wellcome Leap SAVE Programme.

Introduction: Acquired gallbladder diseases in the pediatric population, although rare, are becoming increasingly recognized in clinical practice. The growing number of pediatric cholecystectomies may be attributed to improved diagnostic modalities as well as to shifts in etiological patterns, including the rising prevalence of obesity and metabolic disorders among children and adolescents.Aim: The aim of this study was to analyze the clinical and laboratory presentation, diagnostic evaluation, and treatment of pediatric patients who underwent cholecystectomy at the Clinic for Pediatric Surgery, University of Sarajevo, between 2010 and 2024.Materials and Methods: This retrospective descriptive study included 41 patients who underwent cholecystectomy. Medical records were reviewed to collect data on clinical presentation and disease course. Based on the median age within the sample, patients were stratified into two groups: children under 14 years and those aged 14 years or older.Results: 41 patients were included in the study, comprising 25 (61%) girls and 16 (39%) boys. Between 2010 and 2024, the number of cholecystectomized patients increased by 11.2% annually (p = 0.0057). The median patient age was 14 years. The mean BMI was 23.2 ± 4.66 kg/m²; 51.22% of patients were overweight, and 4.88% were obese. The most frequent diagnosis was chronic calculous cholecystitis, confirmed in 36 patients (87.8%). Spherocytosis was documented in 7 patients (17.7%). Multiple gallstones were present in 29 patients (74.36%), and the majority of sonographically detected gallstones (31 patients, 79.49%) were smaller than 5 mm. Smaller stones tended to occur more frequently (p = –0.53, p < 0.001). Laparoscopic cholecystectomy was performed in 37 patients (90.24%). The average length of hospitalization decreased by approximately 11.9% annually (p < 0.01). Gallstone color was reported in the histopathological findings of 16 patients (41.03%), of which 9 were cholesterol (56.25%) and 7 pigment stones (43.75%). With each additional year of age, the risk of undergoing cholecystectomy increased by 21.5% (p < 0.01). Pigment stones were significantly more frequent in children under 14, while cholesterol stones predominated in those aged 14 years or older (p = 0.0406).Conclusion: The incidence of gallbladder disease is continuously increasing in the pediatric population. Obesity and older pediatric age are significant risk factors for cholelithiasis and cholecystitis. Laparoscopic cholecystectomy remains the standard treatment approach.

Background: Breast cancer remains the most common cancer in women worldwide. Treatment has evolved into multimodal approaches, with pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) serving as a key prognostic marker. The aim of this study was to evaluate the value of inflammatory markers in predicting pCR to NAC in breast cancer. Methods: This cross-sectional study of 74 patients with breast cancer who underwent NAC followed by surgery included demographic, tumor, and immune-inflammatory marker data. Receiver operating characteristic curve analysis and the Youden index were used to determine optimal cutoff values. Univariate and multivariate logistic regression assessed associations between markers and pCR, adjusting for tumor stage, human epidermal growth factor receptor 2 (HER2), and estrogen receptor (ER) status. Results: Our multivariate analysis identified the pan-immune-inflammation value (PIV), HER2 status, and ER status as significant independent predictors of pCR. PIV (OR, 4.28; 95% CI, 1.59–16.88) remained significant among inflammatory markers, while the neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) did not. HER2-positive (OR, 7.45; 95% CI, 2.30–24.15) and hormone receptor (HR)–negative (OR, 7.02; 95% CI, 2.63–18.70) statuses were also strongly associated with pCR. Conclusion: PIV is a robust predictor of pCR in patients with breast cancer receiving NAC, offering a comprehensive reflection of the immune-inflammatory state. Incorporating PIV with tumor-specific markers (e.g., receptor status, Ki-67, grade) may enhance treatment stratification. Further validation in diverse cohorts is warranted.

Introduction. Sentinel lymph node biopsy (SLNB) has significantly advanced axillary staging in clinically node-negative breast cancer, offering lower morbidity compared to traditional axillary lymph node dissection (ALND). Nonetheless, precise prediction of non-sentinel lymph node (non-SLN) involvement remains essential for optimizing surgical decisions and preventing unnecessary ALND. Methods. A retrospective cohort analysis was performed on 176 patients with clinically node-negative breast cancer who underwent SLNB. Clinicopathological data were reviewed to evaluate associations between various predictive factors and non-SLN involvement. Variables analyzed included tumor size, histological grade, lymphovascular invasion (LVI), Ki-67 proliferation index, and sentinel lymph node characteristics. Results. Multivariable logistic regression identified the type of SLN metastasis (OR=21.4; 95% CI 1.7–43.6; p=0.01), the number of positive SLNs (OR=5.66; 95% CI 1.18–36.6; p=0.03), and the number of negative SLNs (OR=0.04; 95% CI 0.006–0.27; p=0.001) as independent predictors of non-SLN metastases. The predictive model demonstrated excellent discriminatory power, with an area under the receiver operating characteristic curve (AUC) of 0.91. Conclusion. Specific clinical and histopathological variables reliably predict non-SLN involvement in SLN-positive breast cancer patients. Incorporation of these predictors into clinical practice may enhance individualized axillary management and reduce unnecessary ALND procedures. Further validation through larger prospective studies is warranted. Key words: Breast Neoplasms, Sentinel Lymph Node Biopsy, Axillary Lymph Nodes, Lymph Node Dissection, Neoplasm Staging.

Background Adjuvant chemotherapy decisions in early-stage, hormone receptor-positive, HER2-negative breast cancer traditionally rely on clinicopathological features such as tumor size, grade, and lymph node status. However, multigene expression assays like MammaPrint offer additional prognostic information that may alter treatment recommendations. This study aimed to assess the level of agreement between MammaPrint-based genomic risk classification and chemotherapy recommendations derived from National Comprehensive Cancer Network (NCCN)-based clinical criteria in a cohort of Bosnia and Herzegovina breast cancer patients. Methods We retrospectively analyzed 66 patients with HR+/HER2-, node-negative early breast cancer treated between 2023 and 2024. All patients underwent MammaPrint testing, which classified tumors as either low risk or high risk for distant recurrence. Clinical risk was assessed using a simplified NCCN-guided algorithm, in which chemotherapy was recommended for tumors >2 cm and/or grade three histology. The primary outcome was the rate of concordance between genomic and clinical risk classifications. Statistical analysis included descriptive summaries, cross-tabulation, and Cohen’s kappa to evaluate agreement. Results Of the 66 patients analyzed, MammaPrint classified 27 (40.9%) as high risk and 39 (59.1%) as low risk. Based on NCCN criteria, 36 patients (54.5%) were considered clinically high-risk and recommended for chemotherapy, while 30 (45.5%) were not. Concordance between genomic and clinical classifications was observed in 37 patients (56.1%), while 29 patients (43.9%) showed discordant results. The most common discordance pattern was a clinically high-risk but genomically low-risk classification, observed in 19 cases (65.5% of discordant pairs). Cohen’s kappa for agreement between methods was 0.136, indicating slight agreement beyond chance. McNemar’s test yielded a χ² value of 10.0 (p = 0.036), suggesting significant asymmetry in discordance patterns. Conclusion This study highlights a substantial rate of discordance between MammaPrint genomic risk and NCCN-based clinical risk assessment. In our cohort, reliance on clinicopathological features alone would have led to different chemotherapy recommendations in over half of the cases. These findings support the clinical utility of multigene assays in refining adjuvant treatment decisions and reducing potential overtreatment in early breast cancer.

Introduction. Primary rectal signet-ring cell adenocarcinoma represents one of the rarest subtypes (1.39% of cases) and is associated with poor prognosis. Case report. We report the case of a 31-year-old female patient with rectal signet-ring cell adenocarcinoma who developed cutaneous metastases. Conclusion. Despite early initiation of treatment, survival in patients with rectal signet-ring cell adenocarcinoma remains poor. Key words: Rectal Neoplasms, Adenocarcinomas, Signet-Ring Cell, Skin Neoplasms.

Introduction. Colon cancer is one of the most common forms of cancer, affecting both sexes equally. The objective tumor response rate (ORR) is an important parameter that proves the effectiveness of treatment in oncology; one of the ways to evaluate ORR is the response evaluation criteria in solid tumors Response evaluation criteria in solid tumors (RECIST). The aim of the research is to determine and compare the impact of the objective response rate in patients with metastatic colorectal cancer and the impact on overall survival (OS) and progression-free survival (PFS). Methods. The work is based on a retrospective (2014-2020) clinical study, with follow-up of patients over a period of 5 years. The research included a total of n=101 patients diagnosed with colorectal cancer (stages II and III according to the American Joint Committee of Cancer -AJCC). Research included n=101 patients, 52% male, 48% female. The youngest patient is 18 years old, and the oldest patient is 80 years old. Results. The average age is 59.69 years. The obtained data show that the largest percentage of Colorectal Cancer-CRC patients are in the third age. Adenocarcinoma is the most common pathohistological verification of colon cancer (77.23%). Overall survival and progression-free time in relation to objective response to therapy (ORR) according to RECIST criteria did not show statistical significance. One patient had a complete response (CR) to therapy, six patients (5.94%) had a partial response (PR) to therapy. Stable disease (SD) was verified in 32.67%, and disease progression (PD) was confirmed in 60.39% of subjects. Conclusion. The extent of objective response to therapy has no influence on overall survival and survival without disease progression in patients with metastatic colorectal disease. Key words: colorectal, cancer, response evaluation criteria in solid tumors.

Aim To investigate prognostic significance of preoperative levels of the Carbohydrate anti-gen 19-9 (CA 19-9) in patients with stage III rectal adenocarcinoma who underwent a treatment at the Clinical Centre of the University of Sarajevo. Materials A retrospective cohort study included 84 patients who underwent radical anterior rectal resection due to grade III rectal adenocarcinoma, followed by adjuvant chemotherapy according to the FOLFOX protocol (Oxaliplatin, Leucovorin, 5-Fluorouracil (5-FU)). The patients were divided into two groups according to CA 19-9 values (≥27 U/mL and <27 U/mL, respectively). Results High pre-operative CA 19-9 values predicted an increased probability of postoperative metastases, especially liver, lung and abdominopelvic metastases, as well as three-year disease-free survival (3Y-DFS) and three-year overall survival (3Y-OS). The 3Y-DFS rate for patients with high CA 19-9 was 64.5%, while for those with low CA 19-9 it was 87.2%. The 3Y-OS rate for patients with high CA 19-9 was 89.8%, while for those with low CA 19-9 it was 65.7%. Univariate and multivariate regression analysis confirmed that a high level of CA 19-9 is an independent predictor for DFS and OS shorter than three years. Conclusion Pre-operatively elevated values of CA 19-9 in rectal adenocarcinoma have a significant role in predicting the outcome in patients with stage III rectal adenocarcinoma.

BACKGROUND Timely and safe elective health care facilitates return to normal activities for patients and prevents emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition. METHODS This was a prospective, international, cohort study conducted between Jan 30 and May 21, 2023, in which any hospital performing inguinal hernia repairs was eligible to take part. Consecutive patients of any age undergoing primary inguinal hernia repair were included. A measurement set mapped to the attributes of WHO's Health System Building Blocks was defined to evaluate access (emergency surgery rates, bowel resection rates, and waiting times) and quality (mesh use, day-case rates, and postoperative complications). These were compared across World Bank income groups (high-income, upper-middle-income, lower-middle-income, and low-income countries), adjusted for hospital and country. Factors associated with postoperative complications were explored with a three-level multilevel logistic regression model. FINDINGS 18 058 patients from 640 hospitals in 83 countries were included, of whom 1287 (7·1%) underwent emergency surgery. Emergency surgery rates increased from high-income to low-income countries (6·8%, 9·7%, 11·4%, 14·2%), accompanied by an increase in bowel resection rates (1·2%, 1·4%, 2·3%, 4·2%). Overall waiting times for elective surgery were similar around the world (median 8·0 months from symptoms to surgery), largely because of delays between symptom onset and diagnosis rather than waiting for treatment. In 14 768 elective operations in adults, mesh use decreased from high-income to low-income countries (97·6%, 94·3%, 80·6%, 61·0%). In patients eligible for day-case surgery (n=12 658), day-case rates were low and variable (50·0%, 38·0%, 42·1%, 44·5%). Complications occurred in 2415 (13·4%) of 18 018 patients and were more common after emergency surgery (adjusted odds ratio 2·06, 95% CI 1·72-2·46) and bowel resection (1·85, 1·31-2·63), and less common after day-case surgery (0·39, 0·34-0·44). INTERPRETATION This study demonstrates that elective health care is essential to preventing over-reliance on emergency systems. We identified actionable targets for system strengthening: clear referral pathways and increasing mesh repair in lower-income settings, and boosting day-case surgery in all income settings. These measures might strengthen non-surgical pathways too, reducing the burden on society and health services. FUNDING NIHR Global Health Research Unit on Global Surgery and Portuguese Hernia and Abdominal Wall Society (Sociedade Portuguesa de Hernia e Parede Abdominal).