• Joshua S Ng-Kamstra, Sumedha Arya, GreenbergSarah L MSLMProgram in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.Division of General and Thoracic Surgery, S, Meera Kotagal, Catherine Arsenault, David Ljungman, Rachel R Yorlets, Arnav Agarwal, Claudia Frankfurter, Anton Nikouline, LaiFrancis Yi XingFYXSkin and Cancer Foundation, Melbourne, Victoria, Australia., Charlotta L Palmqvist, Terence Fu, Tahrin Mahmood, Sneha Raju, Sristi Sharma, Isobel H Marks, Alexis Bowder, Lebei Pi, John G Meara, and Mark G Shrime.
• Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
• BMJ Glob Health. 2018 Jan 1; 3 (3): e000810.

IntroductionThe Lancet Commission on Global Surgery proposed the perioperative mortality rate (POMR) as one of the six key indicators of the strength of a country's surgical system. Despite its widespread use in high-income settings, few studies have described procedure-specific POMR across low-income and middle-income countries (LMICs). We aimed to estimate POMR across a wide range of surgical procedures in LMICs. We also describe how POMR is defined and reported in the LMIC literature to provide recommendations for future monitoring in resource-constrained settings.MethodsWe did a systematic review of studies from LMICs published from 2009 to 2014 reporting POMR for any surgical procedure. We extracted select variables in duplicate from each included study and pooled estimates of POMR by type of procedure using random-effects meta-analysis of proportions and the Freeman-Tukey double arcsine transformation to stabilise variances.ResultsWe included 985 studies conducted across 83 LMICs, covering 191 types of surgical procedures performed on 1 020 869 patients. Pooled POMR ranged from less than 0.1% for appendectomy, cholecystectomy and caesarean delivery to 20%-27% for typhoid intestinal perforation, intracranial haemorrhage and operative head injury. We found no consistent associations between procedure-specific POMR and Human Development Index (HDI) or income-group apart from emergency peripartum hysterectomy POMR, which appeared higher in low-income countries. Inpatient mortality was the most commonly used definition, though only 46.2% of studies explicitly defined the time frame during which deaths accrued.ConclusionsEfforts to improve access to surgical care in LMICs should be accompanied by investment in improving the quality and safety of care. To improve the usefulness of POMR as a safety benchmark, standard reporting items should be included with any POMR estimate. Choosing a basket of procedures for which POMR is tracked may offer institutions and countries the standardisation required to meaningfully compare surgical outcomes across contexts and improve population health outcomes.

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