Mitigating postoperative complications after colorectal cancer surgery: a 4P–3R–failure-to-rescue framework

Although perioperative care has advanced significantly, postoperative morbidity remains a major contributor to adverse clinical and oncological outcomes. This has shifted the focus from merely lowering complication rates toward enhancing system responsiveness and preventing failure-to-rescue (FTR). This review examines how the interaction among several factors, including prevention, surveillance, multidisciplinary rescue and recovery protocols, and effective healthcare systems, influences outcomes after colorectal cancer surgery. A conceptual 4P–3R–FTR model is proposed. The 4P component is a preventive framework including prediction, prehabilitation, precision surgery, and pathway optimisation, emphasising tailored risk stratification, physiological optimisation, high-quality surgery, and enhanced recovery protocols. The 3R component is management-oriented, including recognition, rescue, and recovery, focusing on timely detection of deterioration, timely escalation and rescue protocols, and restoration of functional and oncological recovery. This framework provides a practical roadmap linking prevention, complication management, and healthcare system performance. Special consideration is critical for high-risk cohorts, including elderly, frail, and patients with obesity. Additional high-risk contexts include emergency CRC surgery and low-resource settings, which are associated with higher rates of complications and failure-to-rescue. Improvement in precision and perioperative care may be achieved by adopting emerging innovations. Future directions for improving outcomes after CRC surgery depend on evolving strategies such as AI-based predictive models, remote monitoring, digital ERAS platforms, immunonutrition, and microbiome modulation.