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.

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Background Laparoscopic liver resection is gaining momentum; however, there is limited evidence on its efficacy and safety in obese patients. The aim of this study was to examine the relationship between BMI and outcomes after laparoscopic liver resection (LLR) using a systematic review of the existing literature. Methods A systematic search of Medline (Ovid 1946–present), PubMed (NCBI), Embase (Ovid 1966–present) and Cochrane Library was conducted using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement for parameters of LLR and BMI. Operative, post‐operative and oncological outcomes were recorded. Results Of 1460 abstracts, seven retrospective studies were analysed, published between 2015 and 2017 (study periods 1998–2017). Total patient cohort were classified as 481 obese and 1180 non‐obese with a median age range of 42.5–69.4 years. Variations existed in definitions of obesity (Asia BMI >25 kg/m2, Western BMI >30 kg/m2). Rates of conversion were examined in four studies (0–31%) with one reporting BMI >28 kg/m2 as an independent risk factor. Estimated blood loss and transfusion rates were similar. Operative time was increased in obese patients in one study (P = 0.02). Mortality rates ranged from 0% to 4.3% with no difference between BMI classes. No difference in major morbidity was demonstrated. Bile leak rates were increased in obese groups in one study (0–3.44%, P < 0.05). Wound infections were reported in five studies, with higher rates in obese patients (0–5.8% versus 0–1.9%). Tumour size was comparable in both groups. Completeness of resection was analysed in four studies with one study reporting increased R0 rates in obese patients (P = 0.012). Conclusion This systematic review highlights that current evidence shows LLR in obese patients is safe, however, further studies are required.

Introduction Coronary CT Angiography (CCTA) is a rapidly increasing technique for coronary imaging; however, it exposes patients to ionising radiation. We examined the impact of dose reduction techniques using ECG‐triggering, kVp/mAs reduction and high‐pitch modes on radiation exposure in a large Australian tertiary CCTA service. Methods Data on acquisition modes and dose exposure were prospectively collected on all CCTA scans from November 2009 to March 2014 at an Australian tertiary care centre. A dose reduction algorithm was developed using published techniques and implemented with education of medical staff, radiographers and referrers. Associations of CCTA acquisition to radiation over time were analysed with multivariate regression. Specificity in positive CCTA was assessed by correlation with invasive coronary angiography. Results 3333 CCTAs were analysed. Mean radiation dose decreased from 8.4 mSv to 5.3, 4.4, 3.7, 2.9 and 2.8 mSv (P < 0.001) per year. Patient characteristics were unchanged. Dose reduction strategies using ECG‐triggering, kVp/mAs reduction accounted for 91% of the decrease. High‐pitch scanning reduced dose by an additional 9%. Lower dose was independently related to lower kVp, heart rate, tube current modulation, BMI, prospective triggering and high‐pitch mode (P < 0.01). CCTA specificity remained unchanged despite dose reduction. Conclusion Implementation of evidence‐based CCTA dose reduction algorithm and staff education programme resulted in a 67% reduction in radiation exposure, while maintaining diagnostic specificity. This approach is widely applicable to clinical practice for the performance of CCTA.

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