A Study of Role of Preoperative Albumin Levels and Postoperative Drop in the Prediction of Outcomes of Exploratory Laparotomy

Abstract

Background:

Serum albumin is generally considered to be a predictor of a patient’s nutritional status. Hypoalbuminemia is associated with increased mortality and morbidity in postoperative patients. In this study, we used preoperative serum albumin levels and a drop in postoperative albumin levels to assess various postexploratory laparotomy complications.

Aim:

This study aims to evaluate the role of preoperative albumin levels and their postoperative drop in the incidence and severity of outcomes in exploratory laparotomies.

Study Design:

Prospective observational.

Materials and Methods:

Preoperative and postoperative serum albumin level was observed in 52 patients who underwent exploratory laparotomy for various pathological conditions and were divided into ten groups based on the specific outcomes observed, such as surgical site infections (SSIs), delayed wound healing (DWH), or acute respiratory distress syndrome. Within each group, the relationship between the preoperative albumin levels, their postoperative drop, and the severity of the outcomes was analyzed. The study was conducted over a period from August 2022 to July 2024.

Results:

Among ten outcomes, four outcomes showed significant results. Patients with SSI and DWH showed significant differences in drop-in postoperative albumin levels (P = 0.005), with a mean difference of 0.64810 g/dL. Among anastomotic leak (AL) patients, Out of 52 patients who underwent exploratory laparotomy due to various indications, only 32 had bowel anastomosis, with significant value for AL when equal variances are assumed (P = 0.039) noted. In the mortality category, for preoperative albumin, there is a significant mean difference of 1.2970 (P = 0.001), with higher levels in survivors compared to nonsurvivors. Similarly, postoperative albumin levels show a significant mean difference of 1.18085 (P = 0.002), again favoring survivors.

Conclusion:

Preoperative hypoalbuminemia <3.0 g/dl is a strong and independent risk factor for postoperative morbidity and mortality in gastrointestinal surgeries. Preoperative improvement of nutritional status must be done before undertaking surgery.

INTRODUCTION

Albumin is the most abundant protein in human plasma, accounting for approximately 50%–60% of the total plasma protein content. Normal serum albumin levels range from 3.5 to 5.0 g/dL. It is synthesized primarily by the liver at about 10–15 g/day. It has a half-life of approximately 21 days, making it a reliable indicator of hepatic function and nutritional status.[1] Once in circulation, albumin contributes to osmotic pressure, preventing the leakage of fluids into tissues and thus maintaining blood volume and pressure. It also binds and transports various substances, including bilirubin, calcium, and pharmaceuticals, facilitating their solubility and delivery to target organs.[2] Rich dietary protein sources include meat, dairy products, eggs, and legumes on ingestion, broken down into amino acids, which are then absorbed and transported to the liver, where they are utilized for albumin synthesis.[3] Several conditions can lead to decreased albumin levels in the body, including liver disease, inflammation, sepsis, malnutrition, nephrotic syndrome, and gastrointestinal disorders.[4] Correcting hypoalbuminemia involves addressing the underlying cause and providing nutritional support through high-protein diets or oral protein supplements and administration of intravenous albumin in cases of severe hypoalbuminemia or acute volume depletion.[5] Albumin levels are typically measured using serum samples in clinical laboratories. The most common methods include bromocresol green dye-binding assay and enzyme-linked immunosorbent assay which use antibodies specific to albumin.[6] Here, we would like to study the relationship between preoperative albumin levels and postoperative outcomes after abdominal surgeries. Low albumin levels are linked to impaired immune response and wound healing, increasing the risk of surgical site infections (SSI), albumin compromises the integrity of mucosal barriers and reduces the production of antibodies, facilitating bacterial invasion, exacerbating postoperative pain, anastomotic leak (AL), acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), and predictor of multiple organ dysfunction syndrome (MODS).[7,8,9] Therefore, assessing and correcting albumin levels preoperatively is imperative to improve surgical outcomes and reduce complications associated with exploratory laparotomy. This study aims to investigate the predictive value of preoperative albumin levels and their postoperative drop in patients undergoing exploratory laparotomy, providing a rationale for using albumin as a biomarker to guide preoperative assessments and interventions. Understanding the relationship between albumin levels and surgical outcomes can help tailor preoperative care, enhance recovery, and ultimately improve patient prognosis following exploratory laparotomy.

MATERIALS AND METHODS

Study duration

The study was conducted over a period from August 2022 to July 2024. This duration was selected to ensure an adequate sample size and sufficient follow-up time to capture the relevant postoperative outcomes. The start and end dates marked the comprehensive timeline for patient enrollment, data collection and analysis, and follow-up assessments.

Inclusion criteria

Patients aged between 18 and 70 years presented to the general surgery department and underwent either emergency or elective exploratory laparotomy.

Exclusion criteria

Patients with known cases of alcoholic liver disease, hepatitis, protein-losing enteropathy, uncontrolled diabetes, and chronic respiratory or chronic kidney conditions were excluded from the study.

Study sampling

Patients were divided into ten groups based on the specific outcomes they experienced postsurgery.

1. SSIs

2. Long hospital stay (LHS)

3. Pain

4. Delayed wound healing (DWH)

5. ARDS

6. AKI

7. Burst abdomen (BA)

8. AL

9. MODS

10. Death.

Each group was analyzed to determine the relationship between preoperative albumin levels, their postoperative drop, and the incidence and severity of these outcomes.

Sample size

The sample size is calculated using the formula,n

= standard normal value at 5% level of significance

= 1.96z_1-β = standard normal value at80% power =0.84σ

= ∫ D=0.76 and d = clinically significant difference

= 0.3 Now Substituting the values in equation: N

RESULTS AND ANALYSIS

The study presents a statistical analysis based on 52 patients. Preoperative albumin levels ranged from 1.5 to 5.6 g/dl with an average of 3.79 g/dl and a standard deviation of 0.8575, indicating moderate variability. Postoperatively, albumin levels dropped to arrange between 0.20 and 4.20 g/dl, with a mean of 2.8473 g/dl. Data were analyzed using IBM SPSS (Online software) statistics. The analysis included descriptive statistics, comparative analysis using paired t-tests, correlation analysis using the Pearson coefficient, and outcome analysis. Out of ten variables, four variables presented significant values, such as SSIs, DWH, AL, and mortality.

Pre- and postoperative albumin levels and their drop among patients with and without surgical site infection [Table 1a and b]

Table 1a.

Albumin levels in patients with and without surgical site infection

Group statistics	SSI	n	Mean	SD	SEM
Preoperative albumin	No	28	3.989	0.7365	0.1392
	Yes	24	3.563	0.9440	0.1927
Postoperative albumin	No	28	3.1464	0.63332	0.11969
	Yes	24	2.4983	0.93095	0.19003
Drop in albumin	No	28	0.879	0.5934	0.1121
	Yes	24	0.973	0.6214	0.1268

SD=Standard deviation, SSI=Surgical site infections, SEM=Standard error of mean

Table 1b.

Independent samples test for comparison of albumin levels between patients with and without surgical site infection

Independent samples test	Levene’s test for equality of variances		t-test for equality of means
	F	Significant	t	df	P	Mean difference	SEM	95% CI of the difference
								Lower	Upper
Preoperative albumin
Equal variances assumed	1.203	0.278	1.830	50	0.073	0.4268	0.2332	−0.0416	0.8952
Equal variances not assumed			1.795	43.236	0.080	0.4268	0.2377	−0.0525	0.9061
Postoperative albumin
Equal variances assumed	2.044	0.159	2.970	50	0.005	0.64810	0.21820	0.20983	1.08636
Equal variances not assumed			2.886	39.563	0.006	0.64810	0.22458	0.19405	1.10215
Drop in albumin
Equal variances assumed	0.039	0.845	−0.557	50	0.580	−0.0939	0.1687	−0.4328	0.2449
Equal variances not assumed			−0.555	48.017	0.582	−0.0939	0.1693	−0.4343	0.2465

SEM=Standard error of mean, CI=Confidence interval

The study analyzed albumin levels in patients undergoing exploratory laparotomy, comparing those who developed SSIs to those who did not. Preoperatively, patients without SSI had higher mean albumin levels (3.989 g/dL) than patients having SSI (3.563 g/dL). Postoperatively, non-SSI patients maintained higher albumin levels (3.1464 g/dL) compared to SSI patients (2.4983 g/dL). The drop in albumin was also slightly greater in the SSI group (0.973 g/dL) than in the non-SSI group (0.879 g/dL). Levene’s test indicates equal variances for all variables tested. The t-tests show no significant difference in preoperative albumin levels or the drop in albumin postsurgery, with P = 0.073 and 0.580, respectively. However, there is a significant difference in postoperative albumin levels (P = 0.005), with a mean difference of 0.64810 g/dL, suggesting that lower postoperative albumin levels may correlate with the presence of SSIs. These findings suggest a correlation between lower pre- and postoperative albumin levels and the occurrence of SSIs, highlighting the potential of albumin as a marker for nutritional status and surgical recovery risks.

Comparison of albumin levels between patients with and without delayed wound healing [Table 2a and b]

Table 2a.

Comparison of albumin levels between patients with and without delayed wound healing

Group statistics	DWH	n	Mean	SD	SEM
Preoperative albumin	No	28	3.989	0.7365	0.1392
	Yes	24	3.563	0.9440	0.1927
Postoperative albumin	No	28	3.1464	0.63332	0.11969
	Yes	24	2.4983	0.93095	0.19003
Drop in albumin	No	28	0.879	0.5934	0.1121
	Yes	24	0.973	0.6214	0.1268

SEM=Standard error of mean, SD=Standard deviation, DWH=Delayed wound healing

Table 2b.

Independent samples test for comparison of albumin levels between patients with and without delayed wound healing

Independent samples test	Levene’s test for equality of variances		t-test for equality of means
	F	Significant	t	df	P	Mean difference±SE difference	95% CI of the difference
							Lower	Upper
Preoperative albumin
Equal variances assumed	1.203	0.278	1.830	50	0.073	0.4268±0.2332	−0.0416	0.8952
Equal variances not assumed			1.795	43.236	0.080	0.4268±0.2377	−0.0525	0.9061
Postoperative albumin
Equal variances assumed	2.044	0.159	2.970	50	0.005	0.64810±0.21820	0.20983	1.08636
Equal variances not assumed			2.886	39.563	0.006	0.64810±0.22458	0.19405	1.10215
Drop in albumin
Equal variances assumed	0.039	0.845	−0.557	50	0.580	−0.0939±0.1687	−0.4328	0.2449
Equal variances not assumed			−0.555	48.017	0.582	−0.0939±0.1693	−0.4343	0.2465

CI=Confidence interval, SE=Standard error

The study analyzed albumin levels in patients undergoing exploratory laparotomy, comparing those who had DWH to those who did not. Preoperatively, patients without DWH had higher mean albumin levels (3.989 g/dL) than those with DWH (3.563 g/dL). Postoperatively, non-DWH patients maintained higher albumin levels (3.1464 g/dL) compared to DWH patients (2.4983 g/dL). The drop in albumin was also slightly greater in the DWH group (0.973 g/dL) than in the non-DWH group (0.879 g/dL). The t-tests show no significant difference in preoperative albumin levels or the drop in albumin postsurgery, with P = 0.073 and 0.580, respectively. However, there is a significant difference in postoperative albumin levels (P = 0.005), with a mean difference of 0.64810 g/dL, suggesting that lower postoperative albumin levels may correlate with the presence of DWH. This finding points towards the potential of postoperative albumin as a critical indicator for patient outcomes postsurgery concerning the duration of wound healing.

Group statistics for comparison of albumin levels between patients with and without anastomotic leak among those who had bowel anastomosis [Table 3a and b]

Table 3a.

Group statistics for comparison of albumin levels in patients with and without anastomotic leak

Group statistics	AL	n	Mean	SD	SEM
Preoperative albumin	No	22	3.79	0.791	0.169
	Yes	10	3.200	0.980	0.310
Postoperative albumin	No	22	2.61	0.794	0.169
	Yes	10	2.376	0.904	0.286
Drop in albumin	No	22	1.15	0.723	0.154
	Yes	10	0.624	0.405	0.128

SEM=Standard error of mean, SD=Standard deviation, AL=Anastomotic leak

Table 3b.

Independent samples test for comparison of albumin levels between patients with and without anastomotic leak

Independent samples test	t-test for equality of means
	df	P	Mean difference	SE difference
Preoperative albumin
Equal variances assumed	30.0	0.081	0.586	0.325
Equal variances not assumed		0.117	0.600
Postoperative albumin
Equal variances assumed	30	0.464	0.233	0.316
Equal variances not assumed		0.760	0.122
Drop in albumin
Equal variances assumed	50	0.039	0.531	0.246

SE=Standard error

Out of 52 patients who underwent exploratory laparotomy due to various indications, only 32 had bowel anastomosis. The group statistics compare albumin levels between patients who experienced (22/32 patients) and those who did not experience (10/32 patients) AL after bowel anastomosis during exploratory laparotomy. Patients without AL had higher preoperative albumin levels (mean 3.79 g/dL) compared to those with AL (mean 3.200 g/dL). Postoperative albumin levels were also higher in the no-AL group (mean 2.61 g/dL) compared to the AL group (mean 2.3760 g/dL). The drop in albumin was greater in patients without AL (mean drop 1.15 g/dL) than in those with AL (mean drop 0.654 g/dL). These findings suggest that patients with AL had lower albumin levels both pre- and postoperatively compared to those without AL; however, drop in albumin was found to be greater in patients without AL. Values of both preoperative and postoperative albumin levels are higher in the AL group when compared to the no-AL group; however, the values are not significant. The drop in albumin shows no significant difference when equal variances are not assumed (P = 0.073) but are significant when equal variances are assumed (P = 0.039), indicating a greater drop in the AL group. Overall, patients without AL have higher albumin levels both pre- and postoperatively. They also have a higher drop in albumin levels postoperatively as compared to the no-AL group; which is statistically significant. Hence, the drop in albumin levels postoperatively needs to be monitored and corrected to help prevent this deadly complication.

Group statistics for comparison of albumin levels between patients who survived and those who did not [Table 4a and b]

Table 4a.

Group statistics for comparison of albumin levels between patients who survived and those who did not (mortality)

Group statistics	Death	n	Mean	SD	SEM
Preoperative albumin	No	47	3.917	0.7611	0.1110
	Yes	5	2.620	0.9011	0.4030
Postoperative albumin	No	47	2.9609	0.77993	0.11376
	Yes	5	1.7800	0.69065	0.30887
Drop in albumin	No	47	0.956	0.6106	0.0891
	Yes	5	0.600	0.4416	0.1975

SD=Standard deviation, SEM=Standard error of mean

Table 4b.

Independent samples test for comparison of albumin levels between patients who survived and those who did not (mortality)

Independent samples test	Levene’s test for equality of variances		t-test for equality of means
	F	Significant	t	df	P	Mean difference±SE difference	95% CI of the difference
							Lower	Upper
Preoperative albumin
Equal variances assumed	0.233	0.631	3.566	50	0.001	1.2970±0.3637	0.5665	2.0276
Equal variances not assumed			3.103	4.628	0.030	1.2970±0.4180	0.1960	2.3980
Postoperative albumin
Equal variances assumed	0.091	0.765	3.247	50	0.002	1.18085±0.36370	0.45034	1.91136
Equal variances not assumed			3.588	5.151	0.015	1.18085±0.32915	0.34213	2.01958
Drop in albumin
Equal variances assumed	0.473	0.495	1.264	50	0.212	0.3562±0.2817	−0.2096	0.9220
Equal variances not assumed			1.644	5.772	0.153	0.3562±0.2166	−0.1790	0.8914

SE=Standard error, CI=Confidence interval

The group statistics reveal significant differences in albumin levels between patients who survived and those who did not. Preoperative albumin levels are notably higher in survivors (mean of 3.917) compared to those who did not survive (mean of 2.620). Similarly, postoperative albumin levels are significantly higher for survivors (mean of 2.9609) than for nonsurvivors (mean of 1.7800). The drop in albumin is also greater in survivors (mean of 0.956) compared to those who did not survive (mean of 0.600). This indicates variable differences in albumin levels and their changes associated with survival outcomes. For preoperative albumin, there is a significant mean difference of 1.2970 (P = 0.001), with higher levels in survivors compared to nonsurvivors. Similarly, postoperative albumin levels show a significant mean difference of 1.18085 (P = 0.002), again favoring survivors. However, the drop in albumin between pre- and postoperative levels does not show a significant difference (P = 0.212), suggesting that the change in albumin levels does not vary significantly between the two groups.

Rest variables results showed no significant changes such as LHS [Table 5a and b], postoperative pain [Table 6a and b], ARDS [Table 7a and b], AKI [Table 8a and b], BA [Table 9a and b], MODS [Table 10a and b].

Table 5a.

Pre- and post-operative albumin levels and their drop among patients with and without long hospital stay

Group statistics	LHS	n	Mean	SD	SEM
Preoperative albumin	No	26	3.792	0.9968	0.1955
	Yes	26	3.792	0.7116	0.1396
Postoperative albumin	No	26	2.8077	1.02212	0.20046
	Yes	26	2.8869	0.63218	0.12398
Drop in albumin	No	26	0.977	0.7218	0.1416
	Yes	26	0.867	0.4613	0.0905

SEM=Standard error of mean, SD=Standard deviation, LHS=Long hospital stay

Table 5b.

Independent samples test for comparison of albumin levels between patients with and without long hospital stay

Independent samples test	Levene’s test for equality of variances		t-test for equality of means
	F	Significant	t	df	P	Mean difference±SE difference	95% CI of the difference
							Lower	Upper
Preoperative albumin
Equal variances assumed	3.411	0.071	0.000	50	1.000	0.0000±0.2402	−0.4824	0.4824
Equal variances not assumed			0.000	45.228	1.000	0.0000±0.2402	−0.4837	0.4837
Postoperative albumin
Equal variances assumed	6.175	0.016	−0.336	50	0.738	−0.07923±0.23570	−0.55264	0.39418
Equal variances not assumed			−0.336	41.685	0.738	−0.07923±0.23570	−0.55499	0.39653
Drop in albumin
Equal variances assumed	4.007	0.051	0.655	50	0.516	0.1100±0.1680	−0.2274	0.4474
Equal variances not assumed			0.655	42.499	0.516	0.1100±0.1680	−0.2289	0.4489

SE=Standard error, CI=Confidence interval

Table 6a.

Comparison of albumin levels between patients with no pain and those with moderate pain (5/10)

Group statistics	Pain	n	Mean	SD	SEM
Preoperative albumin	No	37	3.668	0.8750	0.1438
	Yes 5/10	2	3.850	0.7778	0.5500
Postoperative albumin	No	37	2.8259	0.80782	0.13280
	Yes 5/10	2	2.9500	0.49497	0.35000
Drop in albumin	No	37	0.823	0.5235	0.0861
	Yes 5/10	2	0.900	0.2828	0.2000

SEM=Standard error of mean, SD=Standard deviation

Table 6b.

Independent samples test for comparison of albumin levels in patients without and those with moderate pain (5/10)

Independent samples test	Levene’s test for equality of variances		t-test for equality of means
	F	Significant	t	df	P	Mean difference±SE difference	95% CI of the difference
							Lower	Upper
Preoperative albumin
Equal variances assumed	0.204	0.654	−0.288	37	0.775	−0.1824±0.6334	−1.4658	1.1010
Equal variances not assumed			−0.321	1.141	0.797	−0.1824±0.5685	−5.6001	5.2352
Postoperative albumin
Equal variances assumed	0.887	0.352	−0.213	37	0.832	−0.12405±0.58148	−1.30224	1.05414
Equal variances not assumed			−0.331	1.308	0.786	−0.12405±0.37435	−2.90329	2.65518
Drop in albumin
Equal variances assumed	0.782	0.382	−0.205	37	0.838	−0.0773±0.3764	−0.8400	0.6854
Equal variances not assumed			−0.355	1.403	0.769	−0.0773±0.2177	−1.5215	1.3669

SE=Standard error, CI=Confidence interval

Table 7a.

Group statistics for comparison of albumin levels between patients with and without acute respiratory distress syndrome

Group statistics	ARDS	n	Mean	SD	SEM
Preoperative albumin	No	41	3.820	0.8875	0.1386
	Yes	11	3.691	0.7648	0.2306
Postoperative albumin	No	41	2.8463	0.90363	0.14112
	Yes	11	2.8509	0.59406	0.17912
Drop in albumin	No	41	0.956	0.6348	0.0991
	Yes	11	0.795	0.4642	0.1400

SEM=Standard error of mean, SD=Standard deviation, ARDS=Acute respiratory distress syndrome

Table 7b.

Independent samples test for comparison of albumin levels between patients with and without acute respiratory distress syndrome

Independent samples test	Levene’s test for equality of variances		t-test for equality of means
	F	Significant	t	df	P	Mean difference±SE difference	95% CI of the difference
							Lower	Upper
Preoperative albumin
Equal variances assumed	0.155	0.695	0.438	50	0.663	0.1286±0.2935	−0.4609	0.7181
Equal variances not assumed			0.478	17.945	0.638	0.1286±0.2690	−0.4368	0.6940
Postoperative albumin
Equal variances assumed	2.734	0.104	−0.016	50	0.987	−0.00457±0.28889	−0.58482	0.57568
Equal variances not assumed			−0.020	23.961	0.984	−0.00457±0.22803	−0.47524	0.46611
Drop in albumin
Equal variances assumed	1.022	0.317	0.787	50	0.435	0.1616±0.2053	−0.2508	0.5739
Equal variances not assumed			0.942	21.216	0.357	0.1616±0.1715	−0.1949	0.5181

CI=Confidence interval, SE=Standard error

Table 8a.

Group statistics for comparison of albumin levels between patients with and without acute kidney injury

Group statistics	AKI	n	Mean	SD	SEM
Preoperative albumin	No	45	3.816	0.8893	0.1326
	Yes	7	3.643	0.6477	0.2448
Postoperative albumin	No	45	2.8480	0.87923	0.13107
	Yes	7	2.8429	0.60238	0.22768
Drop in albumin	No	45	0.941	0.6421	0.0957
	Yes	7	0.800	0.2000	0.0756

SEM=Standard error of mean, SD=Standard deviation, AKI=Acute kidney injury

Table 8b.

Independent samples test for comparison of albumin levels between patients with and without acute kidney injury

Independent samples test	Levene’s test for equality of variances		t-test for equality of means
	F	Significant	t	df	P	Mean difference±SE difference	95% CI of the difference
							Lower	Upper
Preoperative albumin
Equal variances assumed	1.683	0.200	0.492	50	0.625	0.1727±0.3510	−0.5323	0.8777
Equal variances not assumed			0.620	9.919	0.549	0.1727±0.2784	−0.4483	0.7937
Postoperative albumin
Equal variances assumed	1.334	0.254	0.015	50	0.988	0.00514±0.34567	−0.68916	0.69944
Equal variances not assumed			0.020	10.479	0.985	0.00514±0.26271	−0.57660	0.58689
Drop in albumin
Equal variances assumed	5.328	0.025	0.572	50	0.570	0.1409±0.2464	−0.3539	0.6357
Equal variances not assumed			1.155	30.111	0.257	0.1409±0.1220	−0.1082	0.3899

CI=Confidence interval, SE=Standard error

Table 9a.

Group statistics for comparison of albumin levels between patients with and without burst abdomen

Group statistics	BA	n	Mean	SD	SEM
Preoperative albumin	No	47	3.800	0.8554	0.1248
	Yes	5	3.720	0.9757	0.4363
Postoperative albumin	No	47	2.8566	0.84695	0.12354
	Yes	5	2.7600	0.88769	0.39699
Drop in albumin	No	47	0.929	0.6180	0.0901
	Yes	5	0.860	0.4775	0.2135

SEM=Standard error of mean, SD=Standard deviation, BA=Burst abdomen

Table 9b.

Independent samples test for comparison of albumin levels between patients with and without burst abdomen

Independent samples test	Levene’s test for equality of variances		t-test for equality of means
	F	Significant	t	df	P	Mean difference±SE difference	95% CI of the difference
							Lower	Upper
Preoperative albumin
Equal variances assumed	0.254	0.616	0.196	50	0.845	0.0800±0.4072	−0.7379	0.8979
Equal variances not assumed			0.176	4.678	0.867	0.0800±0.4538	−1.1112	1.2712
Postoperative albumin
Equal variances assumed	0.077	0.783	0.242	50	0.810	0.09660±0.39997	−0.70677	0.89997
Equal variances not assumed			0.232	4.808	0.826	0.09660±0.41577	−0.98511	1.17830
Drop in albumin
Equal variances assumed	0.474	0.494	0.240	50	0.812	0.0685±0.2860	−0.5059	0.6429
Equal variances not assumed			0.296	5.537	0.778	0.0685±0.2318	−0.5103	0.6474

SE=Standard error, CI=Confidence interval

Table 10a.

Group statistics for comparison of albumin levels in patients with and without multiple organ dysfunction syndrome

Group statistics	MODS	n	Mean	SD	SEM
Preoperative albumin	No	47	3.783	0.8830	0.1288
	Yes	5	3.880	0.6301	0.2818
Postoperative albumin	No	47	2.8609	0.86795	0.12660
	Yes	5	2.7200	0.60166	0.26907
Drop in albumin	No	47	0.897	0.6146	0.0897
	Yes	5	1.160	0.4506	0.2015

SD=Standard deviation, SEM=Standard error of mean, MODS=Multiple organ dysfunction syndrome

Table 10b.

Independent samples test for comparison of albumin levels between patients with and without multiple organ dysfunction syndrome

Independent samples test	Levene’s test for equality of variances		t-test for equality of means
	F	Significant	t	df	P	Mean difference±SE difference	95% CI of the difference
							Lower	Upper
Preoperative albumin
Equal variances assumed	1.156	0.288	−0.238	50	0.813	−0.0970±0.4071	−0.9148	0.7207
Equal variances not assumed			−0.313	5.824	0.765	−0.0970±0.3098	−0.8607	0.6667
Postoperative albumin
Equal variances assumed	0.647	0.425	0.352	50	0.726	0.14085±0.39971	−0.66199	0.94369
Equal variances not assumed			0.474	5.942	0.653	0.14085±0.29737	−0.58852	0.87022
Drop in albumin
Equal variances assumed	0.810	0.372	−0.928	50	0.358	−0.2634±0.2837	−0.8333	0.3065
Equal variances not assumed			−1.194	5.721	0.279	−0.2634±0.2205	−0.8095	0.2827

SE=Standard error, CI=Confidence interval

DISCUSSION

The study’s results suggest that patients with lower albumin levels are at a higher risk of complications such as SSI, AL, MODS, and mortality. Therefore, targeted nutritional support and timely interventions are crucial to improving patient prognosis. Preoperative assessments should include serum albumin measurements, and patients identified with hypoalbuminemia should receive nutritional support to optimize their levels before surgery. Postoperative monitoring should continue to ensure that any significant drops in albumin are addressed promptly to prevent complications. Further, interdisciplinary collaboration between surgeons, nutritionists, and critical care specialists is essential to develop comprehensive care plans that address the multifaceted needs of patients. Our study was compared with other studies to know the importance of albumin in preventing postoperative complications. Ge et al. conducted a retrospective study to evaluate whether a decrease in serum albumin within 2 postoperative days (PODs) compared to the preoperative level could predict postoperative complications after colorectal surgery. The study included 626 patients undergoing major colorectal surgery between December 2012 and January 2016. They found that the median decrease in albumin after surgery was 15%, and this decrease was an independent risk factor for overall complications (P < 0.01). The cutoff value was determined to be 15%, and patients with a Δalbumin ≥15% experienced more postoperative major complications, higher comprehensive complication index (CCI), longer postoperative stays, and increased SSIs (P < 0.05) compared to those with a Δalbumin <15%. The study concluded that a 15% reduction in serum albumin within 2 PODs could help identify patients with a high probability of postoperative complications, enabling safer and earlier discharge after colorectal surgery.[10] Labgaa et al. (2016) conducted a prospective cohort study to test postoperative serum albumin drop (ΔAlb) as a marker of surgical stress response and an early predictor of clinical outcomes in major abdominal surgery. The study included 138 patients undergoing elective major abdominal surgery. Serum albumin was measured preoperatively and on PODs 0, 1, 2, and 3. They found that ΔAlb correlated with the modified estimation of physiologic ability and surgical stress score (r = 0.275, P = 0.01) and C-reactive protein increase (r = 0.536, P < 0.001). ΔAlb was also associated with overall complications (r = 0.485, P < 0.001), CCI (r = 0.383, P < 0.001), and length of hospital stay (LOS) (r = 0.468, P < 0.001). A ΔAlb ≥10 g/L yielded a sensitivity of 77.1% and specificity of 67.2% (area under the curve: 78.3%) to predict complications. Patients with ΔAlb ≥10 g/L on POD 1 had a threefold increased risk of overall postoperative complications. The study concluded that early postoperative decrease in serum albumin correlated with the extent of surgery, its metabolic response, and adverse outcomes such as complications and length of stay.[11] Pratik and Roy conducted a prospective observational study from July 2017 to July 2019 on 200 patients undergoing elective major surgeries at a tertiary care center. The study aimed to evaluate preoperative serum albumin levels as a predictor of postoperative morbidity and complications. The mean serum albumin levels of patients with complications (3.09 ± 0.62 mg/dL) were significantly lower compared to patients without complications (3.77 ± 0.83 mg/dL) as determined by the student t-test. The study concluded that proper assessment of preoperative serum albumin can predict postoperative outcomes and complications in major surgeries, with serum albumin levels lower than 3 g/dL associated with an increased risk of serious complications within 30 days postsurgery, including sepsis, acute renal failure, pneumonia, and wound infection.[12] Bhat et al. investigated the role of preoperative serum albumin levels in predicting severe postoperative complications in major gastrointestinal surgery. The prospective observational study included 100 patients from a tertiary care center in northern India, conducted between October 2016 and April 2018. Preoperative serum albumin levels were determined, and patients were categorized based on these levels. Severe postoperative complications were observed in 22% of the patients, with a significant correlation between low preoperative albumin levels and higher grades of complications. The cutoff value for predicting severe postoperative complications was calculated to be 3.1 g/dL (95% confidence interval 0.64–0.87; P < 0.001). Significant correlations were also found between preoperative albumin levels and intensive care unit (ICU) duration, length of hospitalization, and mortality, although the cutoff for postoperative mortality was statistically insignificant (P = 0.104). The study concluded that preoperative hypoalbuminemia below 3.1 g/dL can predict higher complications, prolonged hospitalization, and ICU stay.[13] Naga Rohith et al. investigated the role of preoperative serum albumin levels in predicting postoperative surgical site wound complications in patients undergoing emergency exploratory laparotomy. The study included 60 patients divided into two groups based on albumin levels (<3.5 g/dl and >3.5 g/dL). Results indicated that 65% of the patients had hypoalbuminemia, and among them, 56.4% experienced SSIs (P < 0.001), and 87.2% had wound dehiscence (P < 0.001). In addition, hypoalbuminemia patients had significantly longer hospital stays (P < 0.001). The study concluded that preoperative hypoalbuminemia is a strong predictor of postoperative SSIs, wound dehiscence, and prolonged hospital stays.[14] The study’s descriptive statistics highlighted that preoperative albumin levels ranged from 1.5 to 5.6 g/dL with a mean of 3.792 g/dL, and postoperative levels ranged from 0.20 to 4.20 g/dL with a mean of 2.8473 g/dL. The average drop in albumin was about 0.90 g/dL. The study also noted that the presence of hypoalbuminemia significantly impacted the incidence and severity of various postoperative complications, underscoring the importance of nutritional interventions and continuous monitoring of albumin levels. However, the study also acknowledges its limitations, including the relatively small sample size and the focus on a single type of surgery. Future research should aim to validate these findings in larger and more diverse populations and explore the mechanisms linking hypoalbuminemia to surgical complications. Randomized controlled trials assessing the efficacy of different nutritional interventions and longitudinal studies tracking long-term outcomes could provide deeper insights into the role of albumin in surgical recovery.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.