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.

AimReview the literature from 1990 to 2013 to determine known anatomic sites, risk factors, treatments, and outcomes of head and neck squamous cell carcinoma (HNSCC) in sub-Saharan Africa. MethodsUsing a systematic search strategy, literature pertaining to HNSCC in sub-Saharan Africa was reviewed and patient demographics, anatomic sites, histology, stage, treatment, and outcomes were abstracted. The contributions of human immunodeficiency virus (HIV), human papillomavirus (HPV) and behavioural risk factors to HNSCC in the region were assessed. ResultsOf the 342 papers identified, 46 were utilized for review, including 8611 patients. In sub-Saharan Africa, the oropharyngeal/oral cavity was found to be the most common site, with 7750 cases (90% of all cases). Few papers distinguished oropharyngeal from oral cavity, making identification of possible HPV-associated oropharyngeal squamous cell carcinoma (SCC) difficult. SCC of the nasopharynx, nasal cavity, or paranasal sinuses was identified in 410 patients (4.8% of all cases). Laryngeal SCC was found in 385 patients (4.5% of all cases), and only 66 patients (0.8% of all cases) with hypopharyngeal SCC were identified. In 862 patients with data available, 43% used tobacco and 42% used alcohol, and reported use varied widely and was more common in laryngeal SCC than that of the oropharyngeal/oral cavity. Toombak and kola nut use was reported to be higher in patients with HNSCC. Several papers reported HIV-positive patients with HNSCC, but it was not possible to determine HNSCC prevalence in HIV-positive compared to negative patients. Reports of treatment and outcomes were rare. ConclusionsThe oropharyngeal/oral cavity was by far the most commonly reported site of HNSCC reported in sub-Saharan Africa. The roles of risk factors in HNSCC incidence in sub-Saharan Africa were difficult to delineate from the available studies, but a majority of patients did not use tobacco and alcohol.

clinicaltrials.gov Identifier: NCT01789177.

In a resource limited setting, basic trauma tools such as GCS and heart rate can effectively triage head injury patients, who comprise the most critically ill trauma patients. Improvements in head injury outcome require multifaceted efforts including the development of a trauma system to improve pre-hospital care.

Background Intestinal volvulus is a common cause of mechanical intestinal obstruction (MIO) in Africa. Sigmoid volvulus has been well characterized in both high-income and low-income countries, but there is also a predilection for small bowel volvulus in sub-Saharan Africa. Methods An analysis was performed of the Kamuzu Central Hospital Acute Care Surgery Registry from 2013 to 2019 on patients presenting with intestinal volvulus. Bivariate analysis was performed for covariates based on the intestinal volvulus type. Multivariate Poisson regression models estimated the relative risk of volvulus and mortality. Results A total of 4352 patients were captured in the registry. Overall, 1037 patients (23.8%) were diagnosed with MIO. Intestinal volvulus accounted for 499 (48.1%) of patients with MIO. Sigmoid volvulus, midgut volvulus, ileosigmoid knotting, and cecal volvulus accounted for 57.7% (n = 288), 19.8% (n = 99), 20.8% (n = 104), and 1.6% (n = 8), respectively. Mean age was 46.8 years (SD 17.2) with a male preponderance (n = 429, 86.0%) and 14.8% (n = 74) mortality. Overall, the most common operations performed were large bowel (n = 326, 74.4%) and small bowel (n = 76, 16.7%) resections with 18.0% (n = 90) ostomy formation. Upon regression modeling, the relative risk for volvulus was 2.7 times higher in men than women after controlling for season and age. There was no statistically significant difference in the relative risk of mortality based on the type of volvulus. Conclusion Volvulus is a significant cause of primary bowel obstruction in sub-Saharan Africa. Type of intestinal volvulus is not associated increased risk of mortality. Reasons for increases in the incidence of small bowel volvulus are still largely undetermined.