Postoperative Mortality and Associated Risk Factors in Emergency General Surgery: A Single-Center Cohort Study From Greece

IntroductionEmergency General Surgery (EGS) comprises a heterogeneous group of acute surgical conditions that require prompt evaluation and, frequently, urgent operative intervention.Patients presenting for EGS often have significant comorbidity, physiological derangement, sepsis, or hemodynamic instability, and are exposed to substantially higher postoperative morbidity and mortality than patients undergoing elective surgery.Although contemporary Greek data on emergency laparotomy have recently emerged, outcomes across the broader operatively managed spectrum of EGS remain ill-determined.We aimed to characterize 30-day postoperative mortality and associated risk factors across operatively managed EGS -defined as procedures of immediate or urgent priority -in a single Greek tertiary center. MethodsWe conducted an ambispective, single-center observational cohort study of adults undergoing emergency general surgery of National Confidential Enquiry into Patient Outcome and Death (NCEPOD) immediate or urgent priority at a tertiary academic center in Athens, Greece, between January 2020 and July 2025.The primary outcome was 30-day postoperative mortality.Associations with mortality were examined using univariable logistic regression and a multivariable model incorporating age, American Society of Anesthesiologists (ASA) grade, preoperative sepsis severity, emergency laparotomy, and generalized peritonitis/gross contamination.Established emergency-surgery risk-prediction scores (National Emergency Laparotomy Audit (NELA), Emergency Surgery Acuity Score (ESAS), Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), and Surgical Risk Scale (SRS) were additionally evaluated for discrimination in an exploratory analysis. ResultsOf 2,506 screened cases, 2,040 patients were included, with a 30-day mortality of 7.6% (156/2,040), increasing to 12.5% (52/415) after emergency laparotomy and 11.6% (42/361) among NELA-eligible patients.Mortality varied markedly by diagnosis (0.7% (3/430) for appendicitis to 50.9% (29/57) for bowel ischemia) and increased progressively with ASA grade (2.0% (8/403) for ASA I to 52.9% (9/17) for ASA V) and preoperative sepsis severity (3.6% (41/1141) without sepsis to 45.6% (31/68) with septic shock).In the multivariable model (n=2,019), mortality was independently associated with ASA grade (ASA III vs I: aOR 2.53, 95% CI 1.05-6.08;ASA IV-V vs I: aOR 4.53, 95% CI 1.67-12.30)and preoperative sepsis severity (systemic inflammatory response syndrome (SIRS)/infection vs none: aOR 1.95, 95% CI 1.26-3.03;sepsis or septic shock vs none: aOR 3.52, 95% CI 2.10-5.88).Risk-prediction scores showed moderate discrimination on exploratory analysis (AUROC 0.66-0.72);calibration was not assessed. ConclusionsThirty-day mortality following emergency general surgery was substantial and varied markedly according to underlying diagnosis, ASA grade, and preoperative sepsis severity.In this multivariable model, ASA grade and sepsis severity were independently associated with mortality although these associations were sensitive to model specification and residual confounding by diagnosis cannot be excluded.Established riskprediction scores showed only moderate discrimination in this heterogeneous EGS population, supporting the need for dedicated validation and calibration before their use for risk prediction or benchmarking in Greek practice.