Malnutrition is observed in approximately 35% of postoperative patients with gastrointestinal illnesses. This percentage rises to nearly 55% among patients whose hospital stay is prolonged due to postoperative complications. There is substantial evidence suggesting that malnourished individuals are at a significantly higher risk of developing complications and experiencing mortality when compared to those with adequate nutritional status. [1,2,3]

Initially, the clinical relevance of serum albumin as a nutritional indicator was underestimated. Albumin is classified as a negative acute-phase protein. During acute or sub acute illness, or in response to physiological stress, serum albumin levels decline as a result of altered hepatic metabolism and increased vascular permeability, which facilitates albumin leakage into the interstitial space. This reduction is also observed as a rapid response to surgical stress. Therefore, serum albumin may serve as a useful biomarker for predicting an adverse postoperative course. The aim of this study is to analyze the correlation between preoperative hypoalbuminemia and the surgical complications encountered in patients undergoing emergency abdominal surgery.[4,5]

This was a hospital-based observational study conducted at Mahatma Gandhi Medical College and Hospital, involving 100 patients who underwent emergency abdominal surgery. The study was carried out over a period from July 2024 to September 2024. Only patients without known comorbidities and those who were admitted and operated on within 24 hours of presentation were included in the study. Data collected included the type of surgery performed and the postoperative complications observed.

The baseline standard for serum albumin was considered to be 3.5 g/dL. Patients with serum albumin levels less than 3.5 g/dL were classified as having hypoalbuminemia. The association between preoperative serum albumin levels and postoperative morbidity was then evaluated.

Inclusion Criteria

The study included patients aged 18 years and above who were admitted either for elective or emergency abdominal surgery. Only those who provided informed consent were enrolled in the study.

Exclusion Criteria

Patients were excluded if they had chronic systemic diseases that could influence albumin levels. These included Anemia with hemoglobin levels < 8 g/dL, Liver failure, Nephrotic syndrome and Diabetes mellitus, Patients with associated head injury, Patients with orthopedic injuries, Patients with renal injuries, Patients with chest trauma, Patients who did not provide informed consent.

Ethical clearance for this study was obtained from the Institutional Ethics Committee (Human) of Mahatma Gandhi Medical College and Hospital prior to the initiation of data collection and patient enrollment

A total of 100 patients were included in the study. Among them, 58% were male and 42% were female. All patients were in the age range of 18 to 60 years. Preoperatively, 44 patients (44%) were identified as having hypoalbuminemia (serum albumin < 3.5 g/dL), while 56 patients (56%) had normal albumin levels (≥ 3.5 g/dL). The mean preoperative serum albumin level of the entire study population was 3.26 g/dL, with a standard deviation (SD) of 0.57.

For analytical purposes, patients were divided into two groups:

• Group A: Patients with hypoalbuminemia (serum albumin < 3.5 g/dL)
• Group B: Patients with normal serum albumin levels (≥ 3.5 g/dL)

Table 1: Age-wise Distribution of Patients in Group A and Group B

Table 2: Postoperative Complications in Group A (Hypoalbuminemia)

Table 3: Postoperative Complications in Group B (Hypoalbuminemia)

Out of the 44 patients with hypoalbuminemia, 32 patients developed postoperative complications, which included surgical site infection (SSI), wound dehiscence, anastomotic leak, and prolonged hospital stay (more than 15 days). The remaining 12 patients did not develop any complications.

Table 4: Comparison of Postoperative Complications between Group A and Group B

Postoperative Complications in Normal Albumin Group (Group B): Group B included patients with normal preoperative serum albumin levels (≥ 3.5 g/dL). Out of the 56 patients in this group, 20 patients developed postoperative complications, which included: Surgical Site Infection (SSI), Wound dehiscence, Anastomotic leak, Prolonged hospital stay (more than 15 days). The remaining 36 patients did not experience any postoperative complications. In our study, among the 44 patients in Group A (with hypoalbuminemia), 8 patients developed surgical site infections, 8 patients developed wound dehiscence, 4 patients had anastomotic leaks, and 12 patients experienced a prolonged hospital stay of more than 15 days.

In contrast, among the 56 patients in Group B (with normal serum albumin levels), 6 patients developed surgical site infections, 10 patients had wound dehiscence, 2 patient had an anastomotic leak, and 2 patient experienced a hospital stay exceeding 15 days.

A comparison of complications in the two groups showed a higher overall complication rate in Group A than in Group B.

Preoperative malnutrition has long been recognized as a significant risk factor for postoperative morbidity and mortality, with supporting evidence dating back more than 75 years. Serum total protein levels, particularly albumin, have been widely used in clinical practice as indicators of nutritional status.

Hormones such as insulin and growth hormone enhance albumin synthesis, while pro-inflammatory cytokines such as interleukin-6 (IL-6), interleukin-1 (IL-1), and tumor necrosis factor (TNF) can inhibit its production. Albumin constitutes approximately 75% of oncotic plasma pressure and plays essential roles in binding and transporting molecules, including free fatty acids, bilirubin, steroid hormones, calcium, and copper. It also functions as a lipid-phase antioxidant, regulates inflammation, and minimizes oxidative stress. Furthermore, albumin serves as a critical amino acid source for tissue repair and protein synthesis, particularly in surgical patients.[5,6]

Both intraoperative and preoperative serum albumin levels have been shown to be strong predictors of morbidity and mortality. Hypoalbuminemia is associated with impaired wound healing, decreased collagen formation, and a reduced immune response, all of which contribute to poor surgical outcomes.

In the present study involving 100 patients undergoing emergency exploratory laparotomy, many patients developed postoperative complications, with wound dehiscence and sepsis being the most frequent. The mean preoperative albumin level among patients with complications was 2.78 g/dL. Notably, lower preoperative albumin levels were inversely related to the length of hospital stay—patients with lower albumin levels tended to remain hospitalized for longer durations.

Preoperative serum albumin is a reliable and cost-effective prognostic marker for predicting surgical outcomes, particularly in the context of emergency abdominal surgeries. The findings from our study reinforce the conclusion that hypoalbuminemia is significantly associated with increased postoperative morbidity, including infections, delayed wound healing, anastomotic leaks, and prolonged hospitalization.

Given its simplicity and clinical relevance, serum albumin testing should be routinely included in the preoperative assessment of patients undergoing major abdominal procedures. Ensuring that patients maintain normal albumin levels in the perioperative period may lead to better surgical outcomes and reduce the incidence of postoperative complications.

1. Chen Y, Zheng R, Wu L, Zou X. Preoperative hypoalbuminemia is associated with increased postoperative complications in patients undergoing colorectal surgery: a retrospective cohort study. Int J Colorectal Dis. 2023;38(2):40.
2. Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999;134(1):36–42.
3. Kuzu MA, Terzioğlu H, Genç V, Erkek AB, Ozban M, Sonyürek P, et al. Preoperative nutritional risk assessment in predicting postoperative outcome in patients undergoing major surgery. World J Surg. 2006;30(3):378–90.
4. Hennessey DB, Burke JP, Ni-Dhonochu T, Shields C, Winter DC, Mealy K. Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study. Ann Surg. 2010;252(2):325–9.
5. Huang H, Zhang X, Yang Y, Li C, Zhang X, Ma J. Preoperative serum albumin levels predict the prognosis of patients with gastrointestinal perforation. World J Gastroenterol. 2020;26(27):3964–76.
6. Gupta R, Senagore AJ, Delaney CP, Brady K, Fazio VW. Is it time to relook at albumin as a surgical risk marker? Surgery. 2003;134(4):565–72.