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Research Article | Volume 15 Issue 7 (July, 2025) | Pages 137 - 141
Pre-Operative Serum Albumin as A Predictor of Post Operative Outcome in Emergency Surgeries: An Observational Study in A Tertiary Health Care Centre in Tripura
 ,
 ,
1
Senior Resident, MBBS, MS (General Surgery), Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala 695011.
2
Assistant Professor, MBBS, MS (General Surgery), Department of General Surgery, Agartala Government Medical College & GBP Hospital, Kunjavan, Agartala, 799006.
3
Associate Professor, MBBS, MS (General Surgery), Department Of General Surgery, Agartala Government Medical College & GBP Hospital, Kunjavan, Agartala, 799006
Under a Creative Commons license
Open Access
Received
June 20, 2025
Revised
June 28, 2025
Accepted
July 3, 2025
Published
July 5, 2025
Abstract

Introduction: Hypoalbuminemia has been found to be associated with increased morbidity and mortality in acute surgical patients. Any surgical procedure induces a stressful and catabolic state. Wound healing is also a catabolic process requiring adequate protein and energy reserves. Severely malnourished patients often demonstrate impaired wound healing and an increased predisposition to infection and other postoperative complications. Aims: To evaluate the role of preoperative serum albumin levels as a predictor of postoperative outcomes in patients undergoing emergency surgeries. Materials and Methods: This hospital-based prospective study was conducted in the Department of General Surgery, AGMC & GBP Hospital, from January 2021 to June 2022. A total of 64 patients undergoing emergency abdominal surgeries were included. Serum albumin levels were measured preoperatively. Postoperative outcomes, including surgical site infection, pulmonary complications, ventilatory support, sepsis, ileus, cardiac events, hospital stay duration, and mortality, were recorded and analyzed in relation to albumin levels. Results: Patients with hypoalbuminemia (<3.5 gm/dL) had a significantly higher incidence of postoperative complications, including surgical site infections (p < 0.001), sepsis (p < 0.001), prolonged hospitalization (p < 0.001), and mortality (p < 0.001), compared to those with normal albumin levels. Mean serum albumin levels were significantly lower in patients with complications than those without. Conclusion: Preoperative serum albumin level is a simple, cost-effective, and reliable biochemical marker that can predict postoperative morbidity and mortality in emergency surgical patients. Early identification and nutritional optimization may improve surgical outcomes.

Keywords
INTRODUCTION

Hypoalbuminemia has been found to be associated with increased morbidity and mortality in acute surgical patients. [1] Any surgical procedure is stressful state & a catabolic process. Wound healing requires energy and is a catabolic process. Patients who are severely malnourished demonstrate impaired wound healing and predisposition to infection. They also suffer from deficient immune mechanisms. The catabolic effects of disease or injury can be reversed by adequate nutritional support. The degree of malnutrition is estimated on the basis of weight loss during the past 6 months, physical findings and plasma protein assessment.

 

Malnutrition is commonly seen in about 30 percent of surgical patients with gastrointestinal disease & upto 60 percent of those in whom hospital stay has been prolonged because of postoperative complications. There are various risk assessment general tests and scores that aim to identify morbidity Specific outcomes like surgical site infection, respiratory failure, anastomotic leak, delayed wound healing, sepsis etc.  These complications are more in patients undergoing emergency surgery due to their poor nutritional status. The correct assessment of the nutritional status of such patients is crucial since malnutrition is a risk factor for morbidity & mortality.[2]

 

But there is no consensus on the best method for assessing the nutritional status when used alone. Serum Albumin level is the most readily available and clinically useful parameter. A Serum Albumin level greater than 3.5g/dl suggests adequate protein stores. A Serum albumin level less than 3.5 g/dl raises concern for potential surgical complications. Decrease in the serum albumin level preoperatively which is a risk factor for surgical complications is associated with increased hospital expenditure, increased length of hospital stay and decreased quality of life.[3]

 

One of the best biochemical parameters to assess nutritional status is estimating the serum albumin level and it is the simple and cost-effective. There are various preoperative assessment protocols available to identify patients with risk of operative morbidity and mortality. [4,5]

 

Total protein in the body is around 6 to 8 gm/dl out of which albumin contributes major part approximately 3.5 to 5.5gm/dl.[6] Serum albumin less than 3.5gram/dl is considered as hypoalbuminemia. [7]

MATERIALS AND METHODS

Study Design: Hospital Based Prospective Study

 

Study Setting: Department of General Surgery, AGMC & GBP HOSPITAL

 

Study Duration: The study will be carried out for one and half years w. e. f.  January, 2021 to June, 2022

 

Study Population: All patients who will be undergoing for emergency operation in this study period

 

Sample size: A total of 64 patients undergoing emergency surgeries were included in the study.

 

Sampling Technique:  Consecutive   Sampling Technique

 

Inclusion criteria:

  1. Patient who give consent for the study.
  2. Age above 18 years and below 60 years for both males and females.
  3. Patient presenting to the Department of Surgery requiring emergency operative procedure.

 

Exclusion criteria:

  1. Patient/ close relatives of the patient not giving consent.
  2. Age below 18 years and above 60 years.
  3. Patient with established liver or renal parenchymal disease.
  4. Patients with immunosuppression like diabetes mellitus or taking chemotherapeutic medications.

 

Study Tools:

  1. Blood Tests: LFT, KFT, CBC , CRP, ESR , BLOOD CULTURE
  2. Chest X ray.
  3.  
  4. CECT Whole Abdomen
  5. Ryles tube for gastric decompression.
  6. Foleys Catheter.
  7.  

 

STATISTICAL ANALYSIS-

For statistical analysis, data were initially entered into a Microsoft Excel spreadsheet and then analyzed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism (version 5). Numerical variables were summarized using means and standard deviations, while Data were entered into Excel and analyzed using SPSS and GraphPad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant.

RESULTS

Table 1: Test of normality for serum albumin

Parameter

Kolmogorov-Smirnova

Shapiro-Wilk

Statistic

df

Sig.

Statistic

Df

Sig.

Serum Albumin (gm/dl)

.093

153

.002

.987

153

.184

 

Table 2: Comparing serum albumin levels between patients with and without preop     presentation and respective post op complication

 Serum Albumin (Mean ± S.D)

 

 

YES

NO

T value

P value

Clinical symptoms and signs

Pain abdomen

3.21 ± 0.73

3.80 ± 0.81

2.091

0.038

Vomiting

3.10 ± 0.67

3.55 ± 0.79

3.402

<0.001

Fever

2.96 ± 0.69

3.42 ± 0.72

3.937

<0.001

P/A tenderness

3.19 ± 0.71

3.92 ± 0.89

2.553

0.029

Postoperative complications

Surgical site infection

2.90 ± 0.71

3.46 ± 0.67

4.867

<0.001

Pulmonary complication

2.78 ± 0.62

3.51 ± 0.67

6.81

<0.001

Ventilatory support

2.62 ± 0.66

3.39 ± 0.68

5.776

<0.001

Sepsis

2.53 ± 0.48

3.45 ± 0.67

7.686

<0.001

Prolonged ileus

3.01 ± 0.74

3.32 ± 0.72

2.308

0.024

Cardiac complications

2.32 ± 0.43

3.37 ± 0.68

9.332

<0.001

Prolonged hospitalization

2.83 ± 0.68

3.46 ± 0.67

5.561

<0.001

Mortality

2.29 ± 0.37

3.38 ± 0.68

6.993

<0.001

 

Table 3: Serum albumin associated with various pre-op clinical symptoms and signs

   

Serum Albumin

Clinical symptoms and signs

   

Normal

Low

χ2

P value

Pain abdomen

No

4

3

0.707

0.453

Yes

60

86

Vomiting

No

29

17

12.165

0.001

Yes

35

72

Fever

No

48

44

10.147

0.002

Yes

16

45

P/A tenderness

No

7

3

3.489

0.095

Yes

57

86

Postoperative complications

Surgical site infection

No

51

40

18.646

<0.001

Yes

13

49

Pulmonary complication

No

54

41

23.21

<0.001

Yes

10

48

Ventilatory support

No

60

62

13.369

<0.001

Yes

4

27

Sepsis

No

62

55

25.458

<0.001

Yes

2

34

Prolonged ileus

No

52

59

4.182

0.045

Yes

12

30

Cardiac complications

No

64

69

16.545

<0.001

Yes

0

20

Prolonged hospitalization

No

54

44

19.735

<0.001

Yes

10

45

Mortality

No

64

69

16.545

<0.001

Yes

0

20

 

Figure 1: Line diagram showing the trend line of complication

 

Figure 2: Line diagram showing the trend line of survival

 

The Kolmogorov-Smirnov test showed a statistically significant result (Statistic = 0.093, df = 153, p = 0.002), suggesting deviation from normality. However, the Shapiro-Wilk test was not statistically significant (Statistic = 0.987, DF = 153, p = 0.184), indicating that the distribution of serum albumin values does not significantly deviate from normality. Given that the Shapiro-Wilk test is more appropriate for smaller sample sizes (n < 2000), the data can be considered approximately normally distributed. The mean serum albumin level in patients with pain abdomen was 3.21 ± 0.73 gm/dl, whereas in those without pain abdomen, it was 3.80 ± 0.81 gm/dl. The difference was found to be statistically significant (t = 2.091, p = 0.038). Patients who presented with vomiting had a significantly lower mean serum albumin level of 3.10 ± 0.67 gm/dl, compared to 3.55 ± 0.79 gm/dl in those without vomiting (t = 3.402, p < 0.001). The mean serum albumin level was significantly reduced in patients with fever (2.96 ± 0.69 gm/dl) compared to those without fever (3.42 ± 0.72 gm/dl) (t = 3.937, p < 0.001). P/A Tenderness: Patients with per abdominal tenderness had a lower mean serum albumin level (3.19 ± 0.71 gm/dl) compared to those without tenderness (3.92 ± 0.89 gm/dl), and this difference was statistically significant (t = 2.553, p = 0.029). Patients who developed surgical site infections had a significantly lower mean serum albumin level (2.90 ± 0.71 gm/dl) compared to those without infection (3.46 ± 0.67 gm/dl) (t = 4.867, p < 0.001). The mean serum albumin level in patients with pulmonary complications was 2.78 ± 0.62 gm/dl, which was significantly lower than those without such complications (3.51 ± 0.67 gm/dl) (t = 6.810, p < 0.001). Patients requiring ventilatory support had significantly lower serum albumin levels (2.62 ± 0.66 gm/dl) compared to those not requiring support (3.39 ± 0.68 gm/dl) (t = 5.776, p < 0.001). Those who developed sepsis had a markedly reduced serum albumin level (2.53 ± 0.48 gm/dl) versus those without sepsis (3.45 ± 0.67 gm/dl) (t = 7.686, p < 0.001). Patients with prolonged ileus showed significantly lower serum albumin levels (3.01 ± 0.74 gm/dl) than those without (3.32 ± 0.72 gm/dl) (t = 2.308, p = 0.024). A significantly lower serum albumin level was observed in patients with cardiac complications (2.32 ± 0.43 gm/dl) compared to those without (3.37 ± 0.68 gm/dl) (t = 9.332, p < 0.001). Patients who experienced prolonged hospitalization had a mean serum albumin level of 2.83 ± 0.68 gm/dl, significantly lower than those with shorter stays (3.46 ± 0.67 gm/dl) (t = 5.561, p < 0.001). Patients who died had a significantly lower mean serum albumin level (2.29 ± 0.37 gm/dl) compared to survivors (3.38 ± 0.68 gm/dl) (t = 6.993, p < 0.001). Among patients without pain abdomen, 4 had normal and 3 had low serum albumin levels. Among those with pain abdomen, 60 had normal and 86 had low albumin levels. The association was not statistically significant (χ² = 0.707, p = 0.453). In patients without vomiting, 29 had normal and 17 had low serum albumin, while in those with vomiting, 35 had normal and 72 had low levels. The difference was statistically significant (χ² = 12.165, p = 0.001), indicating a strong association between vomiting and low serum albumin. Among patients without fever, 48 had normal and 44 had low serum albumin levels. Among those with fever, 16 had normal and 45 had low levels. This association was statistically significant (χ² = 10.147, p = 0.002). Patients without abdominal tenderness included 7 with normal and 3 with low serum albumin, while those with tenderness included 57 with normal and 86 with low levels. Although more patients with tenderness had low albumin, the association was not statistically significant (χ² = 3.489, p = 0.095). Among patients without surgical site infection, 51 had normal and 40 had low serum albumin levels, while among those with infection, 13 had normal and 49 had low levels. This association was statistically significant (χ² = 18.646, p < 0.001), indicating a strong link between low albumin and surgical site infections. In patients without pulmonary complications, 54 had normal and 41 had low serum albumin, whereas in those with complications, 10 had normal and 48 had low levels. The association was statistically significant (χ² = 23.210, p < 0.001). Among patients who did not require ventilatory support, 60 had normal and 62 had low serum albumin. In contrast, among those who required ventilatory support, 4 had normal and 27 had low levels. This difference was statistically significant (χ² = 13.369, p < 0.001). Patients without sepsis included 62 with normal and 55 with low serum albumin, while those with sepsis included only 2 with normal and 34 with low albumin. This association was highly significant (χ² = 25.458, p < 0.001). Among patients without prolonged ileus, 52 had normal and 59 had low serum albumin, while among those with ileus, 12 had normal and 30 had low levels. The association was statistically significant (χ² = 4.182, p = 0.045). All patients with cardiac complications (n = 20) had low serum albumin, while among those without cardiac complications, 64 had normal and 69 had low levels. This association was highly significant (χ² = 16.545, p < 0.001). Among patients without prolonged hospitalization, 54 had normal and 44 had low albumin; among those with prolonged hospitalization, 10 had normal and 45 had low albumin. The difference was statistically significant (χ² = 19.735, p < 0.001). All patients who died (n = 20) had low serum albumin, while survivors included 64 with normal and 69 with low levels. The association between low albumin and mortality was statistically significant (χ² = 16.545, p < 0.001).

DISCUSSION

It was a Hospital Based Prospective Study this study was conducted from January, 2021 to June, 2022 Department of General Surgery, AGMC & GBP HOSPITAL .64 Patients were included in this study

 

Proper nutritional support is very important for post-operative outcome of patients. Nutritional assessment is vital part of surgical patient’s management. Different types of nutritional indices are there to predict patient’s outcome. In my study preoperative serum albumin is used for nutritional assessment for emergency operated patients.

 

The present study was compared with the study done by James Gibbs et al ‘Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity’. They collected 46 preoperative, 12 operative and 24 postoperative variables for 87,078 major surgery cases between October 1, 1991, and December 31, 1993. The present study used 1 preoperative variable and 8 postoperative variables.[2]

 

Males constituted 88.2% of the study population of the present study in comparison to 97.1 % (52,642)  of  the similar study by Gibbs et al. The median age of the present study was 36   years and that of the study by Gibbs et al was 61years.

 

All relationships were statistically significant (P <0.001) in the study by Gibbs et al. In the present study only variables like requirement of ventilatory support, sepsis, pulmonary complications and cardiac complications showed statistical significance (P <0.05). This difference could be attributed to the large sample size taken by the Gibbs et al. [2]

 

On comparing with the similar study conducted by Gibbs et al.[2] the present study showed a low mean serum albumin level depicting a poor nutritional status of our patients leading to high morbidity & mortality rate. Maximum patients were males in both the studies. The morbidity rate of both studies decreased with increase in serum albumin levels as shown in the table 29 & 30. Better the serum albumin levels better were the postoperative outcome. The mortality rate was highest in severe hypoalbuminemic group in the present study.

 

Lohsiriwat V et al.,[6]  suggested that pre-operative hypoalbuminemia (<3.5 g/dl) is an independent risk factor for post-operative complications following rectal cancer surgery.

 

A retrospective study by Kudsk et al.[8] showed serum albumin levels below 3.25gm/dl correlated  immensely with complications, length of hospital stay, postoperative stay and mortality.

 

According to the study conducted by Foley et al.,  their data suggest that albumin therapy for the treatment of hypoalbuminemia in critically ill patients, despite its demonstrated value in raising the serum albumin concentration, has no beneficial impact on a variety of outcome variables, including mortality, complication rate, hospital stay, ventilator dependence, or tolerance of  enteral feeding. [9]

 

Mullen et al.[10] studied the impact of BMI on preoperative outcome in patients undergoing major intra-abdominal surgery. Being underweight & lower serum albumin level were associated with higher mortality and wound infection.

Truong A et al.[11] in their study of preoperative hypoalbuminemia in colorectal surgery, found that hypoalbuminemia significantly influences the length of hospital stay & complication rates, specifically surgical site infection , enterocutaneous fistula and DVT formation .

 

Samuel Lalhruaizela et al.[12] showed in their study that patients with pre-operative serum albumin <3 gm/dl had statistically significant early and late post-operative complications. The rate of complication was 100 % in patients with serum albumin <2.1 gm/dl.

 

In a study done by Davenport DL et al.[13] on 183,069 patients subjected to general and vascular surgeries, it was found that a serum albumin < 3.5 g/dl & weight loss > 10% was associated with cardiac complication with a significant p-value (0.0001)

 

Takagi et al.[14] examined the presence of infectious complications in 103 patients who underwent oesophagectomy for thoracic oesophageal cancer. They showed that postoperative day 21 serum albumin level was significantly higher in patients without infectious complications compared with those who had infection.

 

The present study therefore showed that postoperative morbidity and mortality could be predicted by preoperative serum albumin. It showed that patients with serum albumin less than 2.95 g/dl had more postoperative complications than patients with serum albumin  >2.95 g/dl who had less postoperative complications which was statistically significant.

CONCLUSION

The study found that pre-operative serum albumin can be a powerful biomarker for emergency surgical patients, predicting complications and mortality. Patients with a serum albumin level below 2.95 g/dl had higher complications. A higher value predicted no postoperative complications and survival. Serum albumin is a good nutritional indicator, but early detection of hypoalbuminemia requires better nutritional support and post-operative care.

REFERENCES
  1. Bhuyan K, Das S. Preoperative serum albumin level as independent predictor of surgical outcome in acute abdomen. Int Surg J. 2016;3(1):277–9.
  2. Gibbs J, Cull W, Henderson W, Daley J, Hur K, et al. Preoperative serum albumin level as predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999;134(1):36–42.
  3. Hübner M, Mantziari S, Demartines N, Pralong F, Coti-Bertrand P, et al. Postoperative albumin drop is a marker for surgical stress and a predictor for clinical outcome: a pilot study. Gastroenterol Res Pract. 2016;2016:8743187.
  4. Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. 1988;94(6):1176–86.
  5. Boyd O, Grounds RM, Bennett ED. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. 1993;270(22):2699–707.
  6. Lohsiriwat V, Chinswangwatanakul V, Lohsiriwat S, Akaraviputh T, Boonnuch W, et al. Hypoalbuminemia is a predictor of delayed postoperative bowel function and poor surgical outcomes in right-sided colon cancer patients. Asia Pac J Clin Nutr. 2007;16(2):213–7.
  7. MacFie J. Nutrition and fluid therapy. In: Williams NS, Bulstrode CJK, O’Connell PR, editors. Bailey & Love's Short Practice of Surgery. 27th ed. London: CRC Press; 2018. p. 278–89
  8. Kudsk KA, Tolley EA, DeWitt RC, Janu PG, Blackwell AP, Yeary S, et al. Preoperative albumin and surgical site identify surgical risk for major postoperative complications. JPEN J Parenter Enteral Nutr. 2003;27(1):1–9.
  9. Foley EF, Borlase BC, Dzik WH, Bistrian BR, Benotti PN. Albumin supplementation in the critically ill: a prospective, randomized trial. Arch Surg. 1990;125(6):739–42
  10. Mullen JT, Davenport DL, Hutter MM, Hosokawa PW, Henderson WG, Khuri SF, et al. Impact of body mass index on perioperative outcomes in patients undergoing major intra-abdominal cancer surgery. Ann Surg Oncol. 2008;15(8):2164–72
  11. Truong A, Hanna MH, Moghadamyeghaneh Z, Stamos MJ. Implications of preoperative hypoalbuminemia in colorectal surgery. World J Gastrointest Surg. 2016;8(5):353–6
  12. Lalhruaizela S, Lalrinpuia B, Vanlalhruaii, Gupta D. Serum albumin is a predictor for postoperative morbidity and mortality in gastrointestinal surgeries. J Clin Diagn Res. 2020;14(3):PC01–PC03
  13. Davenport DL, Ferraris VA, Hosokawa P, Henderson WG, Khuri SF, Mentzer RM Jr. Multivariable predictors of postoperative cardiac adverse events after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1199–210
  14. Takagi K, Yamamori H, Morishima Y, Toyoda Y, Nakajima N, Tashiro T. Preoperative immunosuppression: its relationship with high morbidity and mortality in patients receiving thoracic esophagectomy. 2001;17(1):13–7
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