Simple Summary: Little is known about factors contributing to early post-operative morbidity and
mortality in low and middle income countries with a paucity of data limiting global efforts to improve
gynaecological cancer care. In this multicentre, international prospective cohort study of women
undergoing gynaecological oncology surgery, we show that low and middle versus high income
countries were associated with similar post-operative major morbidity. Capacity to rescue patients
from surgical complications is a tangible opportunity for meaningful intervention.
Abstract:
Gynaecological malignancies affect women in low and middle income countries (LMICs) at
disproportionately higher rates compared with high income countries (HICs) with little known about
variations in access, quality, and outcomes in global cancer care. Our study aims to evaluate international
variation in post-operative morbidity and mortality following gynaecological oncology surgery
between HIC and LMIC settings. Study design consisted of a multicentre, international prospective
cohort study of women undergoing surgery for gynaecological malignancies (NCT04579861).
Multilevel logistic regression determined relationships within three-level nested-models of patients
within hospitals/countries. We enrolled 1820 patients from 73 hospitals in 27 countries. Minor
morbidity (Clavien–Dindo I–II) was 26.5% (178/672) and 26.5% (267/1009), whilst major morbidity
(Clavien–Dindo III–V) was 8.2% (55/672) and 7% (71/1009) for LMICs/HICs, respectively. Higher
minor morbidity was associated with pre-operative mechanical bowel preparation (OR = 1.474,
95%CI = 1.054–2.061, p = 0.023), longer surgeries (OR = 1.253, 95%CI = 1.066–1.472, p = 0.006), greater
blood loss (OR = 1.274, 95%CI = 1.081–1.502, p = 0.004). Higher major morbidity was associated
with longer surgeries (OR = 1.37, 95%CI = 1.128–1.664, p = 0.002), greater blood loss (OR = 1.398,
95%CI = 1.175–1.664, p 0.001), and seniority of lead surgeon, with junior surgeons three times more
likely to have a major complication (OR = 2.982, 95%CI = 1.509–5.894, p = 0.002). Of all surgeries,
50% versus 25% were performed by junior surgeons in LMICs/HICs, respectively. We conclude that
LMICs and HICs were associated with similar post-operative major morbidity. Capacity to rescue
patients from surgical complications is a tangible opportunity for meaningful intervention.
Keywords: surgery; gynaecological oncology; morbidity; mortality; collaborative researchSimple Summary: Little is known about factors contributing to early post-operative morbidity and
mortality in low and middle income countries with a paucity of data limiting global efforts to improve
gynaecological cancer care. In this multicentre, international prospective cohort study of women
undergoing gynaecological oncology surgery, we show that low and middle versus high income
countries were associated with similar post-operative major morbidity. Capacity to rescue patients
from surgical complications is a tangible opportunity for meaningful intervention.
Abstract:
Gynaecological malignancies affect women in low and middle income countries (LMICs) at
disproportionately higher rates compared with high income countries (HICs) with little known about
variations in access, quality, and outcomes in global cancer care. Our study aims to evaluate international
variation in post-operative morbidity and mortality following gynaecological oncology surgery
between HIC and LMIC settings. Study design consisted of a multicentre, international prospective
cohort study of women undergoing surgery for gynaecological malignancies (NCT04579861).
Multilevel logistic regression determined relationships within three-level nested-models of patients
within hospitals/countries. We enrolled 1820 patients from 73 hospitals in 27 countries. Minor
morbidity (Clavien–Dindo I–II) was 26.5% (178/672) and 26.5% (267/1009), whilst major morbidity
(Clavien–Dindo III–V) was 8.2% (55/672) and 7% (71/1009) for LMICs/HICs, respectively. Higher
minor morbidity was associated with pre-operative mechanical bowel preparation (OR = 1.474,
95%CI = 1.054–2.061, p = 0.023), longer surgeries (OR = 1.253, 95%CI = 1.066–1.472, p = 0.006), greater
blood loss (OR = 1.274, 95%CI = 1.081–1.502, p = 0.004). Higher major morbidity was associated
with longer surgeries (OR = 1.37, 95%CI = 1.128–1.664, p = 0.002), greater blood loss (OR = 1.398,
95%CI = 1.175–1.664, p 0.001), and seniority of lead surgeon, with junior surgeons three times more
likely to have a major complication (OR = 2.982, 95%CI = 1.509–5.894, p = 0.002). Of all surgeries,
50% versus 25% were performed by junior surgeons in LMICs/HICs, respectively. We conclude that
LMICs and HICs were associated with similar post-operative major morbidity. Capacity to rescue
patients from surgical complications is a tangible opportunity for meaningful intervention.
Keywords: surgery; gynaecological oncology; morbidity; mortality; collaborative research