Severity ranking of immunocompromise conditions for patients undergoing emergency surgery: an outcomes-based reassessment of the 2021 consensus classification system published in the World Journal of Emergency Surgery

In 2021, the World Journal of Emergency Surgery published consensus guidelines classifying immunocompromised patients with acute abdomen into “mild-moderate” and “severe” immune deficiency categories to standardize perioperative risk assessment and guide surgical decision-making. We assessed whether published mortality and complication data are consistent with this classification. We conducted a structured literature review of PubMed and MEDLINE (2000–2025) for studies reporting mortality and complications in adult immunocompromised patients undergoing emergency colectomy, cholecystectomy, appendectomy, or small bowel resection, with a non-immunocompromised control group. Of the fifteen immunocompromising conditions in the classification, three were excluded for confounding or insufficient data (burns, trauma, post-splenectomy) and two pairs combined (symptomatic HIV/AIDS with CD4 < 200 cells/mm 3 ; malignancy with and without chemotherapy), yielding ten categories. For each, we calculated procedure-specific relative mortality and complication rates. We defined a severe-risk threshold of greater than 3 × mortality and tested concordance at alternative thresholds (2–4 ×) in a sensitivity analysis. The guidelines classified five conditions as severe (neutropenia, steroid use, HIV < 200 cells/mm 3 , malignancy, transplant) and five as mild-moderate (uremia, advanced age, malnutrition, diabetes, HIV > 200 cells/mm 3 ). Among the severe conditions, three (neutropenia, steroid use, HIV < 200 cells/mm 3 ) showed greater than 3 × mortality risk, with neutropenia highest (~ 12 ×); the other two (malignancy 2–3 × , transplant 1–2 ×) showed only mild-moderate excess risk. Among the mild-moderate conditions, two (uremia 6–7 × , advanced age 2–9 ×) showed excess mortality and complication risk more consistent with severe immunocompromise. Observed procedure-specific mortality and complication data do not consistently support the 2021 consensus severity ranking: four of the ten conditions were discordant with their assigned classification. This analysis suggests reconsidering uremia and advanced age as severe, and malignancy and transplant as mild-moderate. Because immunocompromise severity may influence whether and when patients undergo surgery, these findings highlight a priority for evidence-based refinement of severity ranking in emergency general surgery.