Failure to Rescue After Emergency General Surgery: A Systematic Review of Risk Markers, Structural Attributes, and Actionable Rescue Processes

Failure to rescue (FTR)—death following a major postoperative complication—is a key surgical quality indicator reflecting a health system’s capacity to manage clinical deterioration. The modifiable determinants highlighted in this review refer specifically to actionable clinical, procedural, and health system mechanisms that can be targeted to reduce death following postoperative complications in emergency general surgery (EGS) patients. This review systematically assesses incidence and factors associated with FTR across EGS cohorts. A systematic review of observational studies published up to 10 January 2026, examining FTR in adult patients (aged ≥ 18 years) undergoing non-elective, urgent, or emergency general surgical procedures was conducted across PubMed, Scopus, and Embase. Eleven primary observational cohorts (eight retrospective, two prospective, and one registry study) were evaluated. Data on study design; verbatim FTR definitions; complications; mortality; and patient-, procedure-, and hospital-level characteristics were extracted (PROSPERO: CRD420261450789). Eleven primary studies comprising 3,406,394 adult emergency general surgery patients were included. FTR, major complications, and overall mortality rates ranged from 4.3–30.6%, 15.0% to 55.1%, and 2.1–16.0%, respectively. Patient-level factors consistently associated with FTR included older age (≥65 years), chronic comorbidities, acute organ dysfunction, severe sepsis, and frailty. Procedure-level drivers included high operative urgency (<6 h), intraoperative contamination, and emergency re-laparotomies, whereas laparoscopic approaches were protective. Hospital-level factors evaluated across studies included surgical volume, teaching status, intensive care unit capacity, and care continuity; notably, structural metrics like hospital volume explained minimal risk-adjusted FTR variance, whereas care fragmentation during non-index readmissions significantly increased FTR risk. FTR after emergency general surgery is driven by an interplay of baseline physiological reserve, procedural urgency, and system rescue processes. Key modifiable determinants include minimizing operative delays, attenuating surgical trauma via minimally invasive approaches where appropriate, maintaining care continuity to avoid non-index readmission fragmentation, and deploying consultant-led rapid escalation pathways. Implementing standardized acute care surgical networks and early critical care rescue protocols may help improve survival following major EGS complications.