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 (aims, hypotheses, or objectives) Emergency laparotomy (EL) is a high‐risk surgical procedure associated with considerable morbidity and mortality around the world. A reliable risk‐assessment tool that is specific to patients undergoing EL allows the early identification of high‐risk patients and enables appropriate healthcare resource allocation. The objective of this study was to compare the commonly used Portsmouth‐physiologic and operative severity score for the enumeration of mortality and morbidity (P‐POSSUM) with the recently developed National Emergency Laparotomy Audit (NELA) score in terms of their accuracy for identifying patients at increased risk of 30‐day mortality in a predominantly Asian population. Methods Physiological and operative data from a prospectively collected audit of adult patients undergoing EL in 2018 and 2019 across two tertiary hospitals in Singapore were used to retrospectively calculate both the P‐POSSUM and NELA scores for each patient encounter. This was then compared to actual mortality rates to determine each model's accuracy and precision. Results 830 patients were included in the study with a 30‐day mortality of 5.66%. The area under the receiver operating characteristics curve (AUROC) was similar for both the NELA (0.86, p < 0.001, 95% CI 0.81–0.91) and the P‐POSSUM models (0.84, p < 0.001, 95% CI 0.78–0.89). While the models over‐predicted mortality, overall O:E ratios showed that the NELA model performance was superior to that of P‐POSSUM (0.58 [95% CI 0.43–0.77] compared to 0.34 [95% CI 0.26–0.46]). Conclusion The NELA risk‐prediction model accurately predicts 30‐day mortality in this large cohort of patients undergoing EL and outperforms the current P‐POSSUM model. We recommend that the NELA score should replace the P‐POSSUM score as a model to distinguish between high‐ and low‐risk patients undergoing EL.

Background High-intensity focused ultrasound (HIFU) is a recent noninvasive technique of treating thyroid nodules. Our study aims to investigate the efficacy and safety of HIFU in treating benign thyroid nodules. Methods This is a retrospective analysis of consecutive patients who underwent HIFU of benign thyroid nodules at our institution from July 2017-2018. All procedures were performed by a single surgeon. Patients were evaluated immediately post-procedure, and at subsequent intervals of 1 week, 1 month, 3 months, and 6 months. The primary endpoint was thyroid nodule volume reduction at 6 months posttreatment. Secondary endpoints were post-procedure local complications. Results Ten patients with 13 thyroid nodules were included. The median follow-up period was 426 days (range 238-573). Mean maximum diameter reduced from 2.6 cm (±0.8) pretreatment to 1.4 cm (±0.7, P \ 0.05) 6 months posttreatment. Mean nodule volume reduced from 5.2 cm 3 (±4.2) pretreatment to 1.5 cm 3 (±1.3,P= 0.01) 6 months posttreatment. Mean volume reduction ratio (VRR) at 6 months posttreatment was 63.2% (±22.5, P \ 0.05), with volume reduction of C50% in 10 of 13 (76.9%) nodules. Two nodules (15.4%) showed size increases from 4 months posttreatment. No patients experienced local skin burns or hematomas. Mean pain scores were 1.5 (±1.2) immediate post-procedure, 0.8 (±1.5) at 1 week, and 0.6 (±1.2) at 1 month post-procedure, respectively, with no reports of pain beyond 1 month. Only two (20.0%) patients had early, temporary posttreatment voice hoarseness. Conclusion Our study shows HIFU ablation to be efficacious and safe-with significant thyroid nodule volume reductions, and no significant or prolonged local complications.

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