Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This
study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical
procedures.
Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and
elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time
in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during
the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after
discharge.
Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at
discharge. Patients reported being in severe pain for 10 (i.q.r. 1–30)% of the first week after discharge and rated satisfaction with
analgesia as 90 (i.q.r. 80–100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated
with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-
effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. −1.52
to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low-
and middle-income countries, patient-reported outcomes did not.
Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects
of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge
analgesia should be adopted routinely

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