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.
Zusammenfassung. In diesem Artikel befassen wir uns mit den Gallenblasenkarzinomen, sowie mit den extrahepatischen Cholangiokarzinomen, zu denen perihiläre und distale Tumore gehören. Allen diesen Tumorentitäten gemeinsam ist deren relative Seltenheit sowie die komplexe Diagnosestellung und Therapie, welche einen engen interdisziplinären Austausch erfordern. In der Therapieplanung hat ein differenzierter Einsatz der zur Verfügung stehenden diagnostischen Modalitäten zur präoperativen korrekten Einschätzung der Resektabilität dieser Tumore einen hohen Stellenwert. Insbesondere bei perihilären Cholangiokarzinomen (sogenannte Klatskin-Tumore), wo stets grössere Leberresektionen mit operativer Entfernung der extrahepatischen Gallengänge zum Erreichen einer R0-Resektion notwendig sind, ist eine detaillierte Planung des Eingriffes erforderlich. Diese muss, neben der Sicherstellung einer guten Perfusion und eines adäquaten biliären Abflusses der Leber, auch stets den Erhalt einer ausreichenden Reserve von funktionellem Leberparenchym sicherstellen. Hierzu können mittels Portalvenenembolisation und konsekutiver Hypertrophie des zukünftigen Restparenchyms auch ausgedehnte Resektionen ermöglicht werden. Für lokal fortgeschrittene perihiläre Tumore oder bei zugrundeliegender primär sklerosierenden Cholangitis kann als kurative Therapieoption eine Lebertransplantation nach neoadjuvanter Radiochemotherapie bei streng selektionierten Patienten in Betracht gezogen werden. Bei distalen Cholangiokarzinomen ist eine partielle Duodenopankreatektomie (Whipple-Operation) notwendig, während das Spektrum der operativen Behandlung der Gallenblasenkarzinome Stadien-gerecht, von einer einfachen Cholecystektomie bis zur ausgedehnten Leberresektion mit Rekonstruktion des biliären Abflusses und der vaskulären Versorgung reichen kann. Anschliessend erfolgt üblicherweise bei allen malignen biliären Tumoren eine adjuvante Chemotherapie mit Capecitabine. Im palliativen Setting kann hingegen Cisplatin-Gemcitabine das Überleben verbessern.
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