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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.

Background The two most common general anesthesia techniques are total intravenous anesthesia (TIVA) and venous/inhalation balanced general anesthesia (BGA). It is unclear whether any of these two techniques affect patient perception of the quality of recovery. The aim of this randomized, double-blinded clinical trial was to assess the quality of postoperative recovery of women undergoing laparoscopic cholecystectomy under general anesthesia. We compared patients who received TIVA with those who received BGA. We also evaluated the factors that may decrease patient-perceived quality of postoperative recovery. Methods We prospectively recruited 121 women aged 18-65 years who were scheduled for elective laparoscopic cholecystectomy due to cholelithiasis. These patients were randomized to receive TIVA (target-controlled infusion of propofol and remifentanil) or BGA (continuous remifentanil infusion and sevoflurane inhalation). To measure the quality of postanesthetic and postoperative recovery, we administered the Quality of Recovery-40 (QoR-40) questionnaire 24 hours after the patient awoke from anesthesia. Results All 60 patients in the TIVA group responded to QoR-40 (median, 188 points; minimum 128; maximum 200). Sixty-one patients in the BGA group had a mean QoR-40 score of 186 points (median, 188 points; minimum 146; maximum 200). There was no significant difference in the QoR-40 score between the two groups (p = 0.577). The patients who presented postoperative nausea and vomiting (PONV) and pain had worse perception of the quality of postoperative recovery.

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