Mortality of emergency abdominal surgery in high-, middle- and low-income countries

J E F Fitzgerald, C Khatri, J C Glasbey, M Mohan, R Lilford, E M Harrison, H Holmer, N Hall, S-H Kim, A Negida, Z Jaffry, S J Chapman, S Shu, H Shiwani, J Jeyakumar, C Fermani, R Balmaceda, M Marta Modolo, E Macdermid, N Gobin, R Chenn, C Ou Yong, M Edye, M Jarmin, S K D'amours, D Iyer, D Youssef, N Phillips, J Brown, R George, C Koh, O Warren, I Hanley, M Dickfos, C Nawara, D Öfner, F Primavesi, A R Mitul, K Mahmud, M Hussain, H Hakim, T Kumar, A Oosterkamp, P A Assouto, I Lawani, Y Imorou Souaibou, A Kyaw Tun, C Leung Chong, G H Devadasar, C Leung Chong, M Rashid Minhas Qadir, K Phyo Aung, L Shi Yeo, C Leung Chong, V D Palomino Castillo, M Moron Munhoz, G Moreira, L C Barros De Castro Segundo, S Anderson Khouri Ferreira, M Cassa Careta, S Binna Kim, A Venâncio De Sousa, A Daltri Lazzarini Cury, G Peixoto Soares Miguel, A Vega Carreiro De Freitas, B Pereira Silvestre, J Guasti Pinto Vianna, C Oliveira Felipe, L Alberto Valente Laufer, F Altoe, L Ayres Da Silva, M L Pimenta, T Fernandes Giuriato, P Alves Bezerra Morais, J Souza Luiz, R Araujo, J Menegussi, M Leal, C Vinícius Barroso Lima, L Sarmento Tatagiba, A Leal, D Vinicius dos Santos, G Pereira Fraga, R Lages Simoes, S Stock, S Nigo, J Kabba, T Ebogo Ngwa, J Brown, S King, A Zani, G Azzie, M Firdouse, S Kushwaha, A Agarwal, K Bailey, B Cameron, M Livingston, A Horobjowsky, D L Deckelbaum, T R azek28B Marinkovic, E Grasset, N D'aguzan, E Grasset, J Jimenez, R Macchiavello, Z Zhang, W Guo, J Oh, F Zheng, I Montes, S Sierra, M Mendez, M I Villegas, M C Mendoza Arango, I Mendoza, F A Naranjo Aristizã¡bal, J A Montoya Botero, V M Quintero Riaza, J Restrepo, C Morales, M C Mendoza Arango, H Cruz, A Munera, M C Mendoza Arango, R Karlo, E Domini, J Mihanovic, M Radic, K Zamarin, N Pezelj, M Hache-Marliere, S Batista Lemaire, R Rivas, A Khyrallh, A Hassan, G Shimy, M A Baky Fahmy, A Nabawi, M S Ali Muhammad Gohar, M Elfil, M Ghoneem, M Asal, M Abdelkader, M Gomah, H Rashwan, M Karkeet, A Gomaa, A Hasan, A Elgebaly, O Azzam, A AbdelFattah, A Gouda, A Elshafay, A Gharib, A Menshawy, M Hanafy, A Al-Mallah, M Abdulgawad, M Baheeg, M Alhendy, I A Fattah, A Kenibar, O Osman, M Gemeah, A Mohammed, A Adel, A Gharib, A Mohammed, A Sayed, M Abozaid, A Hafez El-Badri Kotb, A A Ahmed Ata, M Nasr, A Alkammash, M Saeed, N Abd El Hamid, A M Attia, A Abd El Galeel, E Elbanby, K Salah El-Dien, U Hantour, O Alahmady, B Mansour, A M Elkorashy, E M Saeed Taha, K T Lasheen, S Said Elkolaly, N Yosri Elsayed Abdel-Wahab, M A Fathi Abozyed, A Adel, A M Saeed, G Samir El Sayed, J H Youssif, S Magdy Ahmed, N Soubhy El-Shahat, A Hegazy Khedr, A Osama Elsebaaye, M Elzayat, M Abdelraheim, I Elzayat, M Warda, K Naser El Deen, A Essam Elnemr, O Salah, M Abbas, M Rashad, I Elzayyat, D Hemeda, G Tawfik, M Salama, H Khaled, M Seisa, K Elshaer, A Hussein, M Elkhadrawi, A M Afifi, O Saadeldeen Ebrahim, M M Metwally, R Elmelegy, D M Elbendary Elsawahly, H Safa, E Nofal, M Elbermawy, M Abo Raya, A Abdelmotaleb Ghazy, H Samih, A Abdelgelil, S Abdelghany, A El Kholy, F Elkady, M Salma, S Samy, R Fakher, A Aboarab, A Samir, A Sakr, A Haroun, A Abdel-Rahman Al-Aarag, A Elkholy, S Elshanwany, E Ghanem, A Tammam, A M Hammad, Y El Shoura, G El Ashal, H Khairy, S Antar52, S Mehrez, M Abdelshafy, M Gamal Mohamad Hamad, M Farid Hosh, E Abdallah, B Magdy, T Alzayat, E Gamaly, H Elfeki, A Abouzahra, S Elsheikh, F Elgendy, F Abd El-Salam53, O Seifelnasr, M Ammar, A Eysa, A Sadek, A Gamal Toeema, K Shady, A Nasr, M Abuseif, H Zidan, S Abd Elmageed Barakat, N Elsayed, Y Abd Elrasoul, A Elkelany, M Sabry Ammar, M Mustafa, Y Hegazy, M Etman, S Saad, M Alrahawy, A Raslan, M Morsi, A Rslan, A Sabry, H Elwakil, H Shaker, H Zidan, Y Abd-Elrasoul, A Elkelany, H El-Kashef, M Shaalan, A Tarek, A Elwan, A Ragab Nayel, M Seif, D Emadeldin, M Ali Ghonaim, A Almallah, A Fouad, E Adel Sayma, A Elbatahgy, A Solaiman El-Ma'doul, A Mosad, H Tolba, D A Amin Elsorogy, H Ali Mostafa, A Atef Omar, O Sherief Abd El Hameed, A Lasheen, Y Abd El Salam, A Morsi, M Ismail, H Ahmed El-badawy, M Amer, A Elkelany, A Elkelany, A Sabry El-Hamouly, N Ahmed Attallah, O Mosalum, A Afandy, A Mokhtar, A Abouelnasr, S Ayad, R Shaker, R Sakr, R Shaker, M Amreia, S Elsobky, M Mustafa, A Abo El Magd, A Marey, A Tarek Hafez, M Zalabia, M Moamen Mohamed, A Fadel, E Ali Ahmed, A Ali, M Ghassan Alwafai, A Dwydar, S Kharsa, E Mamdouh, H El-Sheemy, I Youssef, A Khairy Aly, A Aldalaq, E Alnawam, D Alkhabbaz, M Saad, S Hussein, A Abo Elazayem, A Ramadan, M Elashmawy, M Mousa, A Nashaat, S Ghanem, Z Oof, A Elwaey, I Elkadsh, M Darweesh, A Mohameden, M Hafez, A Badr, A Badwy, M Abd El Slam, M Elazoul, S Al-Nahrawi, L Eldamaty, F Nada, M Ameen, A Hagar, M Elsehimy, M Aboraya, H Dawoud, S El Mesery, A El Gendy, A Abdelkareem, A Safwan Marey, M Allam, S Shehata, K Abozeid, M Elshobary, A Fahiem, S Sarsik, A Hashish, M Zidan, M Hashish, A Sanad, M Mesalam, S Aql, A Osman Abdelaziz Elhendawy, M Husseini, E Kasem, A Gheith, Y Elfouly, A Ragab Soliman, Y Ibrahim, N Elfouly, A Fawzy, A Hassan, M Rashid, A Salah Elsherbiny, B Sieda, N Badwi, M M Hassan Mohammed, O Mohamed, M Abdulkhalek Habeeb, M Worku, N Starr, S Desta, S Wondimu, N S Abebe, E Thomas, F A Asele, D Dabessa, N Seyoum Abebe, A B Zerihun, P Mentula, A Leppäniemi, V Sallinen, A Scalabre, F Frade, S Irtan, V Graffeille, E Gaignard, Q Alimi, Q Alimi, V Graffieille, E Gaignard, O Abbo, S Mouttalib, O Bouali, E Hervieux, Y Aigrain, N Botto, A Faure, L Fievet, N Panait, E Eyssartier, F Schmitt, G Podevin, V Parent, A Martin, A P Arnaud, C Muller, A Bonnard, M Peycelon, F Abantanga, K Boakye-Yiadom, M Bukari, F Owusu, J Awuku-Asabre, S Tabiri, L D Bray, D Lytras, K Psarianos, A Bamicha, E Kefalidi, G Gemenetzis, C Dervenis, N Gouvas, C Agalianos, M Kontos, G Kouraklis, D Karousos, S Germanos, C Marinos, C Anthoulakis, N Nikoloudis, N s Mitroudis, G Recinos, S Estupinian, W Forno, J R Arévalo Azmitia, C C Ramã­rez Cabrera, R Guevara, M Aguilera, N Mendez, C A Azmitia Mendizabal, P Ramazzini, M Contreras Urquizu, F Tale, R Soley, E Barrios, E Barrios, D E Marroquín Rodríguez, C I Pérez Velásquez, S M Contreras Mérida, F Regalado, M Lopez, M Siguantay, F Y Lam, K J-Y Szeto, C C L Szeto, W S Li, K K K Li, M F Leung, T Mak, S Ng, S S Prasad, A Kirishnan, N Gyanchandani, S Bhat, A Sreedharan, S V Kinnera, B S Kumar, M Rangarajan, Y Reddy, C Venugopal, S Kumar, A Mittal, S Nadkarni, H N Lakshmi, P Malik, N Limaye, S Pai, P Jain, M Khajanchi, S Satoskar, R Satoskar, A bid B in Mahamood, E P Refianti Sutanto, D A Soeselo, C Tedjaatmadja, F N Rahmawati, R Amandito, M Mayasari, R K M Jawad Al-Hasani, H I Ibraheem Al-Hameedi, I A Aziz Al-Azraqi, L Sabeeh, R Kamil, M Shawki, M Mezeil Telfah, A Rasendran, J Sheehan, R Kerley, C Normile, R W Gilbert, J Song, M Dablouk, L Mauro, M O Dablouk, M Hanrahan, P Kielty, E Marks, S Gosling, M Mccarthy, A Rasendran, D Mirghani, S Altaf Naqvi, C S Wong, S Chung, R D'cruz, R Cahill, S G Gosling, M Mccarthy, A Rasendran, C Fahy, J Song, M Hanrahan, D Duarte Cadogan, A Powell, R Gilbert, C Clifford, C Normile, A Driscoll, P Stassen, C Lee, R Bowe, W Hutch, M Hanrahan, H Mohan, M O'Neill, K Mealy, P Danelli, A Bondurri, A Maffioli, M Pasini, G Pata, S Roncali, P Silvani, M Carlucci, R Faccincani, L Bonavina, Y Macchitella, C Ceriani, G Tugnoli, S Di Saverio, K Khattab, M Angel Paludi, D Pata, L Maria Cloro, A Allegri, L Ansaloni, F Coccolini, E Veronese, L Bortolasi, A Hasheminia, G Nastri, M Dal Canto, S Cucumazzo, F Pata, A Benevento, G Tessera, P Paolo Grandinetti, A Maniscalco, G Luca Lamanna, L Turati, G Sgroi, E Rausa, R Villa, M Monteleone, D Merlini, V Grassi, R Cirocchi, A Cacurri, H Waleed, A Diab, F Elzowawi, M Jokubauskas, K Varkalys, D Venskutonis, R Pranevicius, V Ambrozeviciute, S Juciute, A Skardžiukaitė, D Venskutonis, S Bradulskis, L Urbanavicius, A Austraite, R Riauka, J Zilinskas, Z Dambrauskas, P Karumnas, Z Urniezius, R Zilinskiene, A Rudzenskaite, A Usaityte, M Montrimaite, N Kaselis, A Strazdas, K Jokubonis, K Maceviciute, E Laugzemys, A Kolosov, V Jotautas, I Rakita, S Mikalauskas, D Kazanavicius, R Rackauskas, K Strupas, T Poskus, V Beisa, R Rakauskas, E Preckailaite, R Coomber, K Johnson, J Nowers, D Periasammy, A Salleh, A Das, R Goh Ern Tze, M Nirumal Kumar, N A Nik Abdullah, N R Kosai, M Taher, R Rajan, H Y Chong, A C Roslani, C C Goh, M Agius, E Borg, M Bezzina, R Bugeja, M Vella-Baldacchino, A Spina, J Psaila, H Francois-Coridon, C Tolg, J-F Colombani, C Diaz-Zorrilla, A Ramos-De La Medina, S Corro-Diaz Gonzalez, M Jacobe, D Mapasse, E Snyder, R Oumer, M Osman, A Mohammad, L-J Anyanwu, A Sheshe, A Adesina, O Faturoti, O Taiwo, M Habib Ibrahim, A A Nasir, S Itopa Suleiman, A Adeniyi, O Adesanya, A Adebanjo, R Osuoji, K Atobatele, A Ogunyemi, O Wiliams, M Oludara, O Oshodi, A Ademuyiwa, A Oluwagbemiga Lawal, F Alakaloko, O Elebute, A Osinowo, C Bode, A Adesuyi, A Tade, A Adekoya, C Nwokoro, O O Ayandipo, T Akeem Lawal, A E Ajao, S Sani Ali, B Odeyemi, S Olori, A Popoola, A Adeyeye, J Adeniran, W J Lossius, I Havemann, K Thorsen, J K Narvestad, K Søreide, T B Wold, L Nymo, M Elsiddig, M Dar, K F Bhopal, Z Iftikhar, M M Furqan, B Nighat, M Jawaid, A Khalique, A Zil-E-Ali, A Rashid, H Abbas Dharamshi, T Naqvi, A Faraz, A W Anwar, T Muhammad Yaseen, G S Shamsi, T Yaseen, W Anwer, H Paredes Decoud, O Aguilera, I I Zelada Alvarez, J Marcelo Delgado, G M Machain Vega, H A Segovia Lohse, W L Messa Aguilar, J A Cabala Chiong, A C Manchego Bautista, E Huaman, S Zegarra, R Camacho, J M Vergara Celis, D A Romani Pozo, J Hamasaki, E Temoche, J Herrera-Matta, C P García Torres, L M Alvarez Barreda, R Barrionuevo Ojeda, O Garaycochea, M Castro Mollo, M Linares Delgado, F Fujii, A C Manchego Bautista, W L Messa Aguilar, J A Cabala Chiong, S A Durand, C A Arroyo Basto, N M Urbina Rojas, S B Shu Yip, A L Contreras Vergara, A Echevarria Rosas Moran, G Borda Luque, M Rodriguez Castro, R Alvarado Jaramillo, G Manrique Sila, C E Lopez, M Zapata Ponze De Leon, M Machaca, R Coasaca Huaraya, A Arenas, C López, C Milagros Herrera Puma, W Pino, C Hinojosa, M Zapata Ponze De Leon, S Limache, G Manrrique Sila, L-A Mercado Rodriguez, R Melo, J Costa-Maia, N Muralha, F Sauvat, I Dan, M Hogea, P Eduard, R-M Bratu, M Beuran, I-B Diaconescu, B-V Martian, F-M Iordache, M Vartic, L C Vida, L I Muntean, A S Mironescu, V J P Nsengimana, A Niragire, J D L C Allen Ingabire, E Niyirera, N Zanini, E Jovine, G Landolfo, I N Alomar, S A Alnuqaydan, A M Altwigry, M Othman, N Osman, E Alqahtani, M Alzahrani, R Alyami, E Aljohani, I Alhabli, Z Mikwar, S Almuallem, E Aljohani, R Alyami, M Alzahrani, A Nawawi, M Bakhaidar, A A Maghrabi, M Alsaggaf, M Aljiffry, A Altaf, A Khoja, A Habeebullah, N Akeel, N Ghandora, A Almoflihi, A Huwait, A Al-shammari, M Al-Mousa, M Alghamdi, W Adham, B Albeladi, M A Alfarsi, A Mahdi, S Al Awwad, A Altamimi, T Nouh, M Hassanain, S Aldhafeeri, N Sadig, O Algohary, M Aledrisy, A Gudal, A Alrifaie, M AlRowais, A Althwainy, A Shabkah, U Alamoudi, M Alrajraji, B Alghamdi, S Aljohani, A Daqeeq, J J Al-Faifi, V Jennings, N Ngayu, R Moore, V Kong, H Kretzmann, K Connor, D Nel, C Sampson, R Spence, E Panieri, S Rayne, N Sishuba, M Tun, A M Mphatsoe, J A Carreira, E Teasdale, M Wagener, S Botes, D Du Plessis, F Fernandez-Bueno, J Aguilar-Jimenez, J A Garcia-Marin, L S García, L J García Florez, R Darío Arias Pacheco, J Pagnozzi, J H Jara Quezada, J L Rodicio, G Minguez, R Rodríguez-Uría, P Ugalde, C Lopez-Arevalo, L Barneo, J P Gonzales Stuva, I Ortega-Vazquez, L Rodriguez, N Herrera, P Pitigala Arachchi, W S M Kithsiri Janakantha Senanayake, L A J Jayasooriya Arachchige, S Sivaganesh, D I Samaraweera, V Thanusan, A E K Musa, R M H Balila, M A E H Mohamed, H Ali, H Zain Elabdin, A Hassan, S Mahdi, H Ahmed, S Abdoun Ishag Idris, M Elsayed, M Elsayed, M Mahmoud, M Boijsen, P-O Lundgren, U Gustafsson, A Kiasat, F Wogensen, F Wogensen, E Jurdell, A Thorell, H Thorarinsdottir, M Utter, S M Sundstrom, C Wredberg, A Kjellin, J Nyberg, B Frisk, M Sund, L Andersson, U Gunnarsson, Y Cengiz, S Ahlqvist, I Björklund, H Royson, P Weber, H-I Pahlsson, E Borin, M Hjertberg, H Royson, P Weber, R Schmid, D Schivo, V Despotidis, S Breitenstein, R F Staerkle, E Schadde, F Deichsel, A Gerosa, A Nocito, D A Raptis, B Mijuskovic, M Zuber, L Eisner, S Kruspi, K B Reinisch, C Schoewe, A Novak, A F Palma, G Teufelberger, M Kimaro, R King, A Z eynel A Balkan, M Gumar, M Ali Yavuz, U Karabacak, G Lap, B B Ozkan, B B Ozkan, M Karakahya, R Adams, R Morton, L Henderson, R Gratton, K D Clement, K Yu-Ching Chang, D Mcnish, R Mcintosh, W Milligan, B Skelly, H Anderson-Knight, R Lawther, J Onimowo, V Shatkar, S Tharmalingam, E Woin, T Fautz, O Ziff, S Dindyal, S Talukder, S Arman, V Gadhvi, S Talukder, L S Chew, J Heath, N Blencowe, S Hallam, K Gash, G Singh Mannu, D-C Zachariades, A C Snaith, T S Hettiarachchi, A Nesaratnam, J Wheeler, D McCullagh, J M Clements, A Khan, F Koumpa, C Neophytou, J Roth, W C Soon, M Deputy, A Ahmed, A Ashton, J Vincent, J Almy, T Khan, J L Y Allen, C J Mcintyre, D C Marshall, M Sykes, N Behar, H Jordan, Y Rajjoub, T Sherman, T White, A Watts, R Ardley, T Arulampalam, A Shah, D Brown, E Blower, P Sutton, K Gasteratos, D Vimalachandran, C Magee, G Irwin, A Mcguigan, S Mcaleer, C Morgan, S Braungart, K Lafferty, P Labib, A Tanase, C Mangan, L Reza, A Tanase, C Mangan, H Woodward, C Gouldthorpe, M Turner, J R L Wild, T A M Malik, V K Proctor, K Hewage, J Davies, A Dubois, S Sarwary, A Zardab, A Grant, R Mcintyre, Y P Mogan, W Ho, B F Hon Khi Chong, S Tewari, G Humm, E Farinella, N J Hall, N J Wright, C P Major, T Xerri, P De Bono, J Amin, M Farhad, J F Camilleri-Brennan, A G N Robertson, J Swann, J Richards, A Jabbar, M Attard, H Burns, E Macdonald, M Baldacchino, J Skehan, J Camilleri-Brennan, T Falconer Hall, M Gimzewska, G Mclachlan, J Shah, J Giles, S Chiu, B Weber, S Man Yeng Chiu, S Highcock, M Hassan, W Beasley, A Vlachogiorgos, S Dias, G Maharaj, R Mcdonald, A Macdonald, P Witherspoon, A 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Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1·6 per cent at 24 h (high 1·1 per cent, middle 1·9 per cent, low 3·4 per cent; P < 0·001), increasing to 5·4 per cent by 30 days (high 4·5 per cent, middle 6·0 per cent, low 8·6 per cent; P < 0·001). Of the 578 patients who died, 404 (69·9 per cent) did so between 24 h and 30 days following surgery (high 74·2 per cent, middle 68·8 per cent, low 60·5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2·78, 95 per cent c.i. 1·84 to 4·20) and low-income (OR 2·97, 1·84 to 4·81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov).