Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

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  • GlobalSurg Collaborative and National Institute for Health Research Global Health Research Unit on Global Surgery


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, 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.

Bibliographic note

Funding Information: This study was funded by the National Institute for Health Research Global Health Research Unit Grant (NIHR 17–0799) in a subset of contributing countries. We would like to pay tribute to Hosni Khairy Salem, a dedicated key member of the GlobalSurg Collaborative, who tragically lost his life in June, 2020. MIvBH reports personal fees from Mylan, Alesi Surgical, Johnson and Johnson, and Medtronic; grants and non-financial support from Stryker; and grants from Olympus, outside the submitted work. All fees were paid to MIvBH's employing institution. PB reports grants and personal fees from the Medical Research Council (MRC); grants from MRC, National Institute for Health Research Health Technology Assessment, and Wellcome Trust; and personal fees from AG Biotest, outside the submitted work. TPK reports personal fees from Olympus Surgical outside the submitted work. All other authors declare no competing interests.


Original languageEnglish
Pages (from-to)387-397
Number of pages11
JournalThe Lancet
Issue number10272
Early online date21 Jan 2021
Publication statusPublished - 30 Jan 2021

ASJC Scopus subject areas

Sustainable Development Goals