Background: 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).
Methods: 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
Results: 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.
Conclusion: 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 (