Safe surgical care is a core quality indicator within global surgery frameworks. Postoperative complications are a leading source of disability, mortality, and economic loss worldwide and disproportionately affect low- and middle-income countries. This study aimed to generate nationally representative epidemiological data on early postoperative outcomes after cancer surgery in Ethiopia by using a 7-day prospective observational cohort design.
A national prospective observational cohort was conducted across 46 hospitals in Ethiopia. Each hospital selected one month between January and April 2024 for consecutive enrollment of adult patients (age ≥18 years) admitted for inpatient elective or non-elective cancer surgery with a planned overnight stay. Exclusion criteria were planned day surgery, pediatric patients (<18 years), and radiological procedures not requiring anesthesia.
Data were collected by surgeons, medical interns, residents, and anesthetists using a tool adapted from previous international surgical outcome studies (ASOS and ISOS). Collected variables covered preoperative, intraoperative, and postoperative domains, including demographics, comorbidity, ASA physical status, ECOG performance status, procedure type, use of the WHO Surgical Safety Checklist, operative approach, and immediate postoperative disposition. The dataset and collection tools were provided as supplementary materials to the original report.
Primary outcomes were 7-day in-hospital mortality and postoperative complications assessed up to postoperative day 7. Complication severity was classified using Clavien-Dindo grading. Data underwent supervisor review and validation before entry. Analyses were performed in SPSS v25. Categorical variables were summarized with frequencies and percentages; continuous variables were described using means and SDs when normally distributed. Chi-square tests compared categorical groups. Multicollinearity screening used variance inflation factor and tolerance thresholds; variables meeting criteria were included in multivariable binary logistic regression. Univariable analysis identified candidate predictors (p ≤ 0.2), and multivariable models reported adjusted odds ratios (AOR) with 95% confidence intervals; statistical significance was set at p < 0.05.
During the study periods, 265 cancer operations were recorded among 4,412 total surgeries at participating hospitals. Mean age was 46.6 years (SD 14.9) with a slight female predominance (154/265, 58.1%). The majority of patients were classified as low risk by ASA: ASA I 106/265 (40.0%) and ASA II 133/265 (50.2%). ECOG performance status was also low for most patients: ECOG 0 in 112/265 (42.3%) and ECOG 1 in 98/265 (37.0%). Comorbid conditions were present in 96/265 patients (36.2%).
Colorectal procedures were the single most common surgical indication (38/265, 14.5%), followed by breast surgery (27/265, 10.2%). Most operations were elective (160/265, 60.4%) and classified as major procedures (205/265, 77.4%). Laparoscopic operations were rare (3/265, 1.1%). Use of the WHO Surgical Safety Checklist was not universal, with 42/265 (15.8%) of cases documented as not using the checklist. Immediate postoperative critical care admission was required for 43/265 patients (16.2%).
Overall, postoperative complications within 7 days occurred in 84 of 265 patients (31.7%). By Clavien-Dindo grading, Grade I complications occurred in 29/265 (10.9%), Grade II in 30/265 (11.3%), and Grade III or higher (requiring radiological or operative intervention) in 29/265 (11.1%). The most frequent individual complications were superficial surgical site infection in 47/265 (17.8%), deep surgical site infection in 18/265 (6.8%), and bloodstream infection in 11/265 (4.2%). Reoperation (unplanned return to theatre) occurred in approximately one in nine patients (reported in the manuscript). The seven-day postoperative mortality rate (POMR) was 5/265 (1.9%).
After adjustment for confounders in multivariable logistic regression, the study identified several factors significantly associated with increased odds of 7-day postoperative complications:
Variables with p ≤ 0.2 in univariable analyses were considered for the multivariable model after multicollinearity screening.
This national cohort demonstrates a substantial early postoperative morbidity burden after cancer surgery in Ethiopia: nearly one-third of patients experienced complications within seven days despite a cohort with relatively young age and low ASA and ECOG scores. The seven-day POMR of 1.9% approximates national targets and is similar to figures reported by continental and international surgical outcome studies; however, the authors note that a POMR of ~2% in a younger, lower-risk cancer cohort likely indicates worse risk-adjusted mortality compared with older, higher-risk populations elsewhere.
The complication rate reported here (≈31.7%) exceeds rates reported in the Africa Surgical Outcomes Study and the International Surgical Outcomes Study (~17–18%), suggesting that factors beyond individual patient physiology—such as delayed diagnosis, inadequate preoperative optimization, limited access to minimally invasive approaches, inconsistent use of the WHO Surgical Safety Checklist, intraoperative technique, and constrained postoperative monitoring and critical care capacity—are important contributors. The authors highlight that approximately 40% of postoperative adverse events in LMIC settings are linked to hospital- and system-level factors, reinforcing the need for investments in diagnostic, perioperative, and critical care infrastructure.
The observed reoperation rate (about one in nine) is higher than in some prior series and is noted as a key quality indicator reflecting failures across the surgical care pathway; reducing avoidable returns to theatre is emphasized as a priority for quality improvement.
In this multicenter, prospective 7-day cohort of cancer surgeries in Ethiopia, one in three patients developed postoperative complications, one in nine required reoperation, and one in 53 died within seven days. Independent risk factors for early complications included emergency surgery, comorbidity, ECOG III, and age over 45 years. The authors conclude that system-level gaps in infrastructure and perioperative processes likely contribute substantially to adverse outcomes and call for evidence-based interventions to strengthen surgical systems, expand critical care capacity, improve preoperative optimization, increase adherence to safety checklists, and support quality improvement initiatives targeted to cancer surgical care in Ethiopia.