Failure to rescue after major gynecologic cancer surgery: A National Surgical Quality Improvement Program analysis

OBJECTIVE Failure to rescue (FTR), defined as mortality following a postoperative complication, is a more comprehensive quality metric than complication or mortality rates alone. This study evaluated the incidence of FTR and associated risk factors in major gynecologic oncology surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program was queried for patients undergoing gynecologic oncology procedures between 2013 and 2019 and 2022-2024; data from 2020 to 2021 were excluded due to pandemic-related disruption. Primary outcome was FTR, defined as death within 30 days among patients with at least one postoperative complication. Multivariable logistic regression was used to adjust for factors associated with FTR. RESULTS Among 100,054 patients undergoing major gynecologic oncology surgery, 5.5% experienced one or more postoperative complications and the overall FTR rate was 4.8%. Procedure was not independently associated with FTR. On multivariable analysis, any severe complication was most strongly associated with FTR (OR 4.73, 95% CI 3.45-6.50). In the adjusted model, hypoalbuminemia (OR 2.84, 95% CI 2.07-3.89), perioperative transfusion (OR 1.63, 95% CI 1.17-2.27), and increasing age (OR 1.03 per year, 95% CI 1.02-1.04) were also significantly associated with FTR. Patients who experienced FTR had earlier time to first complication and earlier reoperation compared with survivors. CONCLUSIONS Complication severity, and markers of reduced physiologic reserve, rather than procedure complexity, are the patient-level factors driving FTR following major gynecologic cancer surgery. These findings support targeted preoperative optimization and intensified postoperative surveillance for high-risk patients.