作者
Stephen R Knight,Catherine A Shaw,Riinu Pius,Thomas M Drake,Lisa Norman,Adesoji O Ademuyiwa,Adewale O Adisa,Maria Lorena Aguilera,Sara W Al-Saqqa,Ibrahim Al-Slaibi,Aneel Bhangu,Bruce M Biccard,Peter Brocklehurst,Ainhoa Costas-Chavarri,Kathryn Chu,Anna J Dare,Muhammed Elhadi,Cameron J Fairfield,J Edward Fitzgerald,Dhruv Ghosh,James Glasbey,Mark I. van Berge Henegouwen,J.C. Allen Ingabire,T. Peter Kingham,Marie Carmela M. Lapitan,Ismaïl Lawani,Bettina Lieske,Richard J. Lilford,Janet Martin,Kenneth A. McLean,Rachel J. Moore,Dion Morton,Dmitri Nepogodiev,Faustin Ntirenganya,Francesco Pata,Thomas Pinkney,Ahmad Uzair Qureshi,Antonio Ramos-De la Medina,Aya M Riad,Hosni Salem,J. Simões,Richard K. Spence,Neil J. Smart,Stephen Tabiri,Hannah J. Thomas,Thomas G. Weiser,Malcolm A. West,John Paul Whitaker,Ewen M Harrison,Arben Gjata,Maria Marta Modolo,Sebastian King,Erick Chan,Sayeda Nazmun Nahar,Ade Waterman,Dominique Vervoort,Alemayehu Ginbo Bedada,Bernardo De Azevedo,Ana Gabriela Figueiredo,Manol Sokolov,Venerand Barendegere,Gerald Ekwen,Arnav Agarwal,Qinyang Liu,Juan Camilo Correa,Kalisya Luc Malemo,Jacques Bake,Jakov Mihanović,Kamila Kuncarová,Julius Orhalmi,Hosni Salem,Jyri Teras,Aristotelis Kechagias,Alexis P Arnaud,Judith Lindert,Vasileios Kalles,Maria-Lorena Aguilera-Arevalo,Gustavo Recinos,Zsolt Baranyai,Basant Kumar,Harish Neelamraju Lakshmi,Sanoop K. Zachariah,Philip Alexander,Sunil Kumar Venkatappa,C S Pramesh,Radhian Amandito,Christina Fleming,Luca Ansaloni,Gianluca Pellino,Ahmed M Altibi,Ibrahim R. Nour,Intisar Hamdun,Ali M. Ghellai,Donatas Venskutonis,Tomas Poskus,Justas Zilinskas,Precious Malemia,Yong Yong Tew,Elaine Borg,Sarah Ellul
摘要
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.