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.
Gastrointestinal stromal tumors (GIST) account for 1% to 3% of gastrointestinal tract tumors and are the most common of the mesenchymal tumors. Carcinogenesis of GIST arises in the interstitial cells of Cajal (ICC) and in the myenteric plexus of the gastrointestinal tract due to a mutation of the kinase receptor (KIT, also known as CD117) and the platelet-derived growth factor A (PDGFA) gene leading to activation of the tyrosine kinase receptor. The exact incidence and prevalence of GIST is not known. Symptoms of GIST are non-specific; they present with GI bleeding due to ulceration (50%), abdominal pain (20% to 50%), dysphagia (esophageal GIST) and GI obstruction (10% to 30%) (7,10). Signs include abdominal mass and fullness. A computerized tomographic (CT) scan is the preferred imaging to evaluate GIST. Diagnosis is confirmed by immunohistochemical (IHC) staining a of biopsy sample for medical treatment tyrosine kinase inhibitors (TKI). Surgical resection with negative microscopic margins is the gold standard treatment of GIST. TKI are required for tumor reduction to increase chances of respectability (neoadjuvant therapy) or to prevent recurrence and reduce the progression of advanced, resectable GIST.
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