英国爱丁堡大学Ewen M Harrison团队研究了82个国家癌症手术后死亡率和并发症的全球变化。2021年1月21日，该研究发表在《柳叶刀》杂志上。

80%的癌症患者需要手术治疗，但中低收入国家（LMICs）的早期结局比较数据很少。研究组比较了世界各地医院乳腺癌、结直肠癌和胃癌手术的术后结局，并重点关注疾病分期和并发症对术后死亡率的影响。研究组进行了一项多中心、国际前瞻性队列研究，招募在全身麻醉或神经轴麻醉下接受原发性乳腺癌、结直肠癌或胃癌手术，需要皮肤切口的成年患者。主要预后为术后30天内死亡或严重并发症。

2018年4月1日至2019年1月31日，研究组从82个国家的428家医院招募了15958名患者，其中9106名来自31个高收入国家，2721名来自23个中等偏上收入国家，4131名来自28个中等偏下收入国家。与高收入国家的患者相比，LMICs患者的病情更为严重，低收入或中低收入国家的胃癌（校正比值比为3.72）、结直肠癌（4.59），中高收入国家的结直肠癌（2.06）的30天死亡率较高。

乳腺癌的30天死亡率没有差异，但在低收入或中低收入国家（6.15）和中高收入国家（3.89），主要并发症后死亡的患者比例最高。并发症后的术后死亡部分归因于患者因素（60%），部分归因于医院或国家（40%）。缺乏持续可用的术后护理设施与LMICs每100例主要并发症中有7-10例死亡密切相关。癌症分期本身并不能解释死亡率或术后并发症的早期变化。

研究结果表明，LMICs癌症手术后较高的死亡率并不能完全由疾病的后期表现来解释。将病人从手术并发症中解救出来才是最有意义的干预。通过加强围手术期护理系统以发现和干预常见并发症，癌症手术后的早期死亡有望减少。

附：英文原文

Title: Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

Author: Stephen R Knight, Catherine A Shaw, Riinu Pius, Thomas M Drake, Lisa Norman, Adesoji O Ademuyiwa, Adewale O Adisa, Maria Lorena Aguilera, Sara W Al-Saqqa, Ibrahim Al-Slaibi, Aneel Bhangu, Bruce M Biccard, Peter Brocklehurst, Ainhoa Costas-Chavarri, Kathryn Chu, Anna Dare, Muhammed Elhadi, Cameron J Fairfield, J Edward Fitzgerald, Dhruv Ghosh, James Glasbey, Mark I. van Berge Henegouwen, J.C. Allen Ingabire, T Peter Kingham, Marie Carmela Lapitan, Ismal Lawani, Bettina Lieske, Richard Lilford, Janet Martin, Kenneth A Mclean, Rachel Moore, Dion Morton, Dmitri Nepogodiev, Faustin Ntirenganya, Francesco Pata, Thomas Pinkney, Ahmad Uzair Qureshi, Antonio Ramos-De la Medina, Aya Riad, Hosni Khairy Salem, Joana Simes, Richard Spence, Neil Smart, Stephen Tabiri, Hannah Thomas, Thomas G Weiser, Malcolm West, John Whitaker, Ewen M Harrison, Arben Gjata, Maria Marta Modolo, Sebastian King, Erick Chan, Sayeda Nazmun Nahar, Ade Waterman, Dominique Vervoort, Ismal Lawani, Alemayehu Ginbo Bedada, Bernardo De Azevedo, Ana Gabriela Figueiredo, Manol Sokolov, Venerand Barendegere, Gerald Ekwen, Arnav Agarwal, Anna Dare, Qinyang Liu, Juan Camilo Correa, Kalisya Luc Malemo, Jacques Bake, Jakov Mihanovic, Kamila Kuncarová, Julius Orhalmi, Hosni Salem, Jyri Teras, Aristotelis Kechagias, Alexis P Arnaud, Judith Lindert, Stephen Tabiri, Vasileios Kalles, Maria-Lorena Aguilera-Arevalo, Gustavo Recinos, Zsolt Baranyai, Basant Kumar, Harish Neelamraju Lakshmi, Sanoop Koshy Zachariah, Philip Alexander, Sunil Kumar Venkatappa, C Pramesh, Radhian Amandito, Christina Fleming, Luca Ansaloni, Francesco Pata, Gianluca Pellino, Ahmed M. Altibi, Ibrahim Nour, Intisar Hamdun, Muhammed Elhadi, Ali M. Ghellai, Donatas Venskutonis, Tomas Poskus, Justas Zilinskas, John Whitaker, Precious Malemia, Yong Yong Tew, Elaine Borg, Sarah Ellul, Antonio Ramos-De la Medina, fatima Zahraa Wafqui, David W Borowski, Anne Sophie van Dalen, Cameron Wells, Harissou Adamou, Adesoji Ademuyiwa, Adewale Adisa, Kjetil Sreide, Ahmad Uzair Qureshi, Ibrahim Al-Slaibi, Sara Al Saqqa, Osaid Alser, Haya Tahboub, Helmut Alfredo Segovia Lohse, Sebastian Shu Yip, Marie Carmela Lapitan, Piotr Major, Joana Simes, António Sampaio Soares, Matei Razvan Bratu, Andrey Litvin, Armen Vardanyan, JC Allen Ingabire, Ainhoa Costas-Chavarri, Ahmad Gudal, Naif Albati, Jovan Juloski, Bettina Lieske, Miran Rems, Sarah Rayne, Stephanie Van Straten, Yoshan Moodley, Kathryn Chu, Rachel Moore, Irene Ortega Vázquez, Jaime Ruiz-Tovar, Kithsiri Janakantha Senanayake, Sujeewa Priyantha Bandara Thalgaspitiya, Omer Abdelbagi Omer, Anmar Homeida, Yucel Cengiz, Daniel Clerc, Muhammad Alshaar

Issue&Volume: 2021-01-21

Abstract:

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 15958 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.

DOI: 10.1016/S0140-6736(21)00001-5

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00001-5/fulltext