An estimated 310 million patients undergo surgery worldwide each year.¹ The International Surgical Outcomes Study reported that, globally, 26.8% of patients who underwent major surgery had postoperative complications, and 24.3% of those who underwent low abdominal surgery developed complications.² These findings are similar to those of a previous study.³ Postoperative complications after major surgery have been shown to increase the length of stay (LOS), cost, and mortality.^4-6 Moreover, the presence of postoperative complications after colorectal surgery was associated with decreased long-term survival, independent of patient, disease, and treatment factors.³

An estimated 310 million patients undergo surgery worldwide each year.¹ In the United States, 1 million total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures are performed annually, with an expectation of growth in the coming years.² The International Surgical Outcomes Study³ showed that 16.5% of patients who underwent orthopedic surgery experienced complications. The incidence of complications in THA and TKA was 3.2% to 8.0%,⁴ with an important variability between centers.^4,5 Postoperative complications after THA and TKA have been shown to increase hospital length of stay (LOS).⁶ Kehlet⁷ described the concept of the multimodal approach to recovery in 1997. The Enhanced Recovery After Surgery (ERAS) program that entails an evidenced-based protocol based on a wide literature search was initiated by Ljungqvist et al⁸ in the ERAS study group, which later developed into the ERAS Society. The ERAS protocol includes a variable number of multidisciplinary perioperative measures whose initial goal is to improve recovery and reduce morbidity, which will result in secondary benefits, including reductions in LOS, convalescence, and costs.⁹ Observational studies¹⁰ and randomized clinical trials¹¹ have shown that ERAS was associated with improved outcomes in patients undergoing THA and TKA, mainly a decrease in LOS.^12,13

Introduction Postoperative morbidity and mortality in older patients with comorbidities undergoing gastrointestinal surgery are a major burden on healthcare systems. Infections after surgery are common in such patients, prolonging hospitalisation and reducing postoperative short-term and long-term survival. Optimal management of perioperative intravenous fluids and inotropic drugs may reduce infection rates and improve outcomes from surgery. Previous small trials of cardiac-output-guided haemodynamic therapy algorithms suggested a modest reduction in postoperative morbidity. A large definitive trial is needed to confirm or refute this and inform widespread clinical practice. Methods The Optimisation of Perioperative Cardiovascular Management to Improve Surgical Outcome II (OPTIMISE II) trial is a multicentre, international, parallel group, open, randomised controlled trial. 2502 high-risk patients undergoing major elective gastrointestinal surgery will be randomly allocated in a 1:1 ratio using minimisation to minimally invasive cardiac output monitoring to guide protocolised administration of intravenous fluid combined with low-dose inotrope infusion, or usual care. The trial intervention will be carried out during and for 4 hours after surgery. The primary outcome is postoperative infection of Clavien-Dindo grade II or higher within 30 days of randomisation. Participants and those delivering the intervention will not be blinded to treatment allocation; however, outcome assessors will be blinded when feasible. Participant recruitment started in January 2017 and is scheduled to last 3 years, within 50 hospitals worldwide. Ethics/dissemination The OPTIMISE II trial has been approved by the UK National Research Ethics Service and has been approved by responsible ethics committees in all participating countries. The findings will be disseminated through publication in a widely accessible peer-reviewed scientific journal. Trial registration number ISRCTN39653756.

Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. National Institute for Health and Care Research.