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.

Poor weekend handover has been implicated as one of the causes of observed higher mortality rates at weekends in UK hospitals. In a large teaching hospital we, a group of junior doctors, set about improving the quality and effectiveness of weekend handover. We used the Model for Improvement to implement a weekend handover sticker through an iterative process using multiple Plan/Do/Study/Act (PDSA) cycles. Over the 16 week study period the number of completed weekend tasks increased by 30% and the number of patients with a documented weekend handover increased by nearly 50%.Junior doctors are well positioned to notice the quality and safety shortcomings within hospitals, and by using effective improvement methods they can improve these systems at little or no cost.

The practice of partial mastectomy (PM) in patients with breast cancer has gained momentum over total mastectomy since the results of randomized clinical trials that have provided evidence demonstrating equivalent survival. 1 But in recent years there has been a relative decline in PM compared to bilateral mastectomies, which has been attributed to inadequate esthetic outcomes after PM without reconstruction, which ultimately affects patient satisfaction and their health-related quality of life. 2 On the other hand, PM with immediate reconstruction -what we define as oncoplastic breast surgery (OPBS) -has been proven to be a safe and efficacious means of improving both aesthetics outcomes compared to PM alone without affecting oncological outcomes. 3 Despite the benefits of OPBS, its nationwide utilization has never been precisely quantified. To facilitate future efforts to increase its availability to appropriate candidate patients, this study aims to establish the recent rate and temporal trends of national utilization of OPBS.The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was reviewed for the period 2006-2015 to identify all women 18 years and older who were diagnosed with invasive breast cancer or carcinoma in situ, and underwent PM, as well as identify the subset of women who also underwent any reconstructive procedure during the 30-day postoperative period.The primary outcome was the overall rate of OPBS for the study period, and the temporal trends from 2006 to 2015. The secondary outcome was the annual trend for each OPBS technique: volume displacement (VD), breast reduction (BR), volume reduction (VR), prosthesis, and mastopexy. All statistical tests were two-sided, and p-value of < 0.05 was considered significant. A total 91,129 women underwent PM during the period 2006-2015 of which 4.2% ( n = 3777

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