Deaths linked to treatable emergency surgical conditions are rising in the US
National death rate was about 50% higher in 2020 than in 1999 and 86% higher in rural communities
Key Takeaways
Death rates associated with three common emergency general surgery conditions, which are rarely fatal when treated promptly, rose about 50% over two decades among U.S. adults ages 18 to 64, according to a national analysis of nearly 20,000 deaths.
The difference was greater in rural communities, where the death rate was 86% higher in 2020 than in 1999, compared with 49% higher in urban communities.
Researchers examined deaths involving appendicitis, acute cholecystitis, and abdominal wall hernia with obstruction or gangrene, which are common emergency conditions that typically have low death rates when treated promptly.
The findings will be presented at the American College of Surgeons Clinical Congress 2026 in Washington, Sept. 26-29.
WASHINGTON — Death rates associated with three common, treatable emergency general surgery conditions rose about 50% among U.S. adults ages 18 to 64 between 1999 and 2020 — and rose nearly twice as fast in rural communities as in urban ones, according to a national analysis of nearly 20,000 deaths.
The research will be presented at the American College of Surgeons (ACS) Clinical Congress 2026 in Washington, Sept. 26-29, where thousands of surgeons will convene to advance surgical quality, patient safety, and access to care.
“These are conditions surgeons treat every day, and patients usually do well when they reach the operating room in time,” said Vishnu Mani, MBBS, FACS, first author of the abstract, emergency general surgery medical director, and vice chair of surgery for OSF HealthCare in Peoria, Illinois. “What we found is that more working-age adults are dying with these conditions than two decades ago, which raises important questions about whether patients are getting to surgical care in time, especially in rural communities, and whether workforce shortages or other pressures are contributing.”
Study Details
Led by a team at OSF Saint Francis Medical Center, researchers analyzed data from the CDC WONDER Multiple Cause of Death database. The analysis included adults ages 18 to 64 whose deaths were associated with appendicitis, acute cholecystitis, or an abdominal wall hernia with obstruction or gangrene. These common emergency general surgery conditions generally have low mortality when treated promptly.
The conditions were documented on death certificates as contributing to the death but were not necessarily the primary cause. As a result, the analysis could not establish that the emergency surgical condition itself caused the death.
Among 19,601 deaths associated with the three emergency surgical conditions included in the analysis:
The national death rate was about 50% higher in 2020 than in 1999, increasing from 0.4 to 0.6 deaths per 100,000 people. In rural communities, the rate was 86% higher in 2020 than in 1999, compared with 49% higher in urban communities.
More recent data showed that the number of deaths remained elevated, increasing from 938 in 2021 to 973 in 2024, a 3.7% increase. Deaths increased 6.1% in rural communities compared with 3.2% in metropolitan communities. These figures reflect total deaths rather than population-based death rates.
Death rates were consistently higher among males than females and increased with age, peaking among adults ages 55 to 64.
The study was not designed to determine what caused the increase or whether timely access to emergency surgical care contributed to the findings. Additionally, the analysis used unadjusted death rates, meaning the findings may not account for changes in the age or other characteristics of the population over time. The COVID-19 pandemic may also have influenced mortality during some years included in the analysis, but the study did not separately evaluate its impact.
Further research is needed to understand what may be driving the increase, including whether timely access to emergency surgical care, workforce availability, underlying health conditions, or other factors may have contributed to the findings.
“We saw increases across sex, age, region, and geography, which tells us this is not one group of patients or one corner of the country,” said Faran Bokhari, MD, MBA, FACS, FCCP, chair of surgery at OSF HealthCare, trauma medical director, and senior author of the abstract. “The next question is why. We need to understand whether gaps in timely access to surgical care, workforce capacity, underlying health, or other factors are driving what we are seeing. That is exactly the kind of question the surgical community should be taking on together.”
Co-authors are Samreen Rizwan Shaikh, MD; Arshpreet Kaur, MBBS, MS; Shugofta Aziz, MBBS; and Anoosh Farooqui, MBBS, MPH.
Disclosures: Authors have no relevant disclosures to report.
Citation: Mani V, et al. Failure of Timely Surgical Access? Rising Mortality from Treatable Emergency Conditions in U.S. Working-Age Adults — a CDC WONDER Analysis 1999-2020; 2018-2024. Scientific Forum, American College of Surgeons (ACS) Clinical Congress 2026.
Note: Research abstracts presented at the ACS Clinical Congress Scientific Forum are reviewed and selected by a program committee but are not yet peer reviewed.
# # #
About the American College of Surgeons
The American College of Surgeons (ACS) is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The ACS is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The ACS has approximately 95,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the ACS.
Follow the ACS on social media: X | Instagram | YouTube | LinkedIn | Facebook
Method of Research
Data/statistical analysis
Subject of Research
People
COI Statement
Authors have no relevant disclosures to report.
Underweight patients face 92% increased odds of death after emergency general surgery
Researchers analyzing ACS NSQIP data from more than 334,000 patients find that underweight patients face the highest risk of death, and that those who are both underweight and frail have the worst outcomes, including longer hospital stays
Key Takeaways
Patients who are underweight prior to emergency general surgery are at increased risk of death following the surgical procedure.
Patients who are both frail and underweight have the worst clinical outcomes after emergency general surgery, with a mortality rate of nearly 10%.
Frailty reduces the protective effect of excess weight known as the obesity paradox: compared with normal-weight patients who were not frail, frail patients with obesity had 10% to 65% increased odds of death.
These findings will be presented at the American College of Surgeons Clinical Congress 2026 in Washington, Sept. 26-29.
WASHINGTON — Underweight patients are more likely to die after emergency general surgery than patients who are normal weight or overweight, and patients who are both frail and underweight face an even higher risk of death and other adverse clinical outcomes, according to new research findings. The study drew on the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) database, which covers more than 334,000 adults who had emergency general surgery between 2019 and 2024.
The research will be presented at the American College of Surgeons (ACS) Clinical Congress 2026 in Washington, Sept. 26-29, where thousands of surgeons will convene to advance surgical quality, patient safety, and access to care.
“Our study shows that patients who are both underweight and frail have the worst outcomes. We also saw that frailty reduces the positive impact of the obesity paradox — the finding that patients who are overweight, but not at the extremes of obesity, tend to have better outcomes. That protective effect is lost if a patient is frail,” said lead study author Ellen Cohn, MD, MPH, a third-year general surgery resident at the University of Chicago.
“What we take away from this study is that risk can be mitigated. We can make real-world changes to body mass index (BMI), and physical therapy can reduce frailty. What is unique about our study is that we were able to look at the impact of BMI and frailty together,” she said.
Using the ACS NSQIP database, researchers identified all adults, age 18 and older, in the U.S. who had emergency general surgery procedures between 2019 and 2024. ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals. More than 600 hospitals participate in the ACS NSQIP adult program, which began enrolling private sector hospitals beginning in 2004.
The ACS NSQIP data allowed researchers to evaluate the relationship between BMI and level of frailty on outcomes including death, hospital length of stay, and readmission rates 30 days after initial admission, as well as the interaction between BMI and frailty and their combined associated risk on these outcomes. Frailty was assessed on a scale with values from one to five, with one indicating patients who had one comorbidity such as diabetes or chronic obstructive pulmonary disease and five indicating patients who had five diseases and were severely frail.
Study Results
Among 334,278 patients included in the analysis, 37.6% were frail, more than one in three.
After adjusting for clinical factors, underweight patients had the highest risk of death, with 92% increased odds compared with normal-weight, non-frail patients. In contrast, obese patients had lower odds of death than normal-weight patients: 43% lower at a BMI of 30.0–34.9 and 27% lower at 35.0–39.9. At a BMI of 40 or higher, there was no significant difference.
Frailty alone was associated with 59% increased odds of death.
Compared to patients who were normal weight and not frail, those who were both underweight and frail had the worst outcomes across all measures: 9.8% mortality, 15.8% readmission rates, an average length of stay of 8.2 days, and an 88.5% discharge-to-home rate. For comparison, non-frail patients had a discharge to home rate of 96.9% and normal weight patients 90.3%.
Frailty reduced the protective effect of obesity on mortality. People who were both frail and obese faced 22% increased odds of death, whereas those who were obese but not frail remained 7% less likely to die after emergency general surgery.
“While the focus of our study was on underweight and frail patients, we were surprised to find that obese patients did better,” said study co-author Justin S. Hatchimonji, MD, assistant professor of surgery in the section of trauma and acute care surgery at the University of Chicago.
“I think recognizing the importance of not only underweight status, but also frailty, helps emergency general surgeons plan for postoperative outcomes and think about how to best manage these patients over the long term.”
Dr. Cohn said the findings can be used to improve postoperative outcomes regardless of frailty scores.
“Thinking about older patients, it’s important to focus on what we can affect: nutrition, making sure protein goals are met, bone health, and vitamins,” she said. “Keeping patients healthy that way can have a bigger impact on outcomes than the other comorbidities that make up the frailty score. We know that you can change underweight status and as a result get a better outcome.”
A limitation of the study is that a large database study cannot prove cause and effect, only an association.
Co-authors are Hans Strobl, MD; Phillip Dowzicky, MD, FACS; Abid D. Khan, MD, FACS; and Diane N. Haddad, MD.
Disclosures: Authors have no disclosures to report.
Citation: Cohn E, et al. The Synergistic Risk of Underweight Status and Frailty in Emergency General Surgery. Scientific Forum, American College of Surgeons (ACS) Clinical Congress 2026.
Note: Research abstracts presented at the ACS Clinical Congress Scientific Forum are reviewed and selected by a program committee but are not yet peer reviewed.
# # #
About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has approximately 95,000 members and is the largest organization of surgeons in the world. "FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
Follow the ACS on social media: X | Instagram | YouTube | LinkedIn | Facebook
Method of Research
Data/statistical analysis
Subject of Research
People
COI Statement
Authors have no disclosures to report.
