title: Preoperative albumin and surgical site identify surgical risk for major postoperative complications.
abstract: BACKGROUND
  Although malnutrition contributes to morbidity, studies of pre- and postoperative nutrition often include well-nourished patients unlikely to benefit from therapy and usually do not stratify by the site of surgical pathology. This study evaluates whether perceived preoperative markers of nutritional status recorded in charts correlates with postoperative complications and resource use in patients who receive no preoperative nutrition support and reinterprets the results of several conflicting randomized, prospective studies in this context.
  
  
  METHODS
  This is a retrospective cohort study of 526 surgical patients who had preoperative serum albumin levels measured and were undergoing elective esophageal, gastric, pancreaticoduodenal, or colon surgery between 1992 and 1996 who could have received preoperative nutrition but did not.
  
  
  RESULTS
  Most medical records contained inadequate analysis of preoperative nutritional status, but preoperative albumin correlated inversely with complications, length of stay, postoperative stay, intensive care unit (ICU) stay, mortality, and resumption of oral intake. Patients undergoing esophageal or pancreatic procedures sustained a significantly higher complication rate at most albumin levels, whereas colonic surgery resulted in lower complication rates at the same albumin levels. Resource use (eg, length of stay and ICU stay) related to these complication rates; esophageal and pancreatic procedures used the most resources and colon procedures used the fewest at most albumin levels. This lack of appreciation for nutritional risk and operative site can explain discrepancies in outcome noted in several randomized, prospective nutritional studies and must be applied to the design and implementation of new studies.
  
  
  CONCLUSIONS
  Elective, non-emergent esophageal and pancreatic procedures performed in patients who could have had surgery delayed for preoperative nutrition, but did not, result in higher risk than colon surgery at any given level of serum albumin below 3.25 g/dL. Patient populations in trials should be stratified by operative site and by markers of nutritional status. Degree of hypoalbuminemia and other potential markers of nutritional status may explain many of the discrepancies between trials of nutrition support. Preexisting hypoalbuminemia in patients undergoing elective surgery remains underappreciated, unrecognized, and untreated in many hospitalized patients.
authors.affiliation: University of Wisconsin Medical School, Department of Surgery, Madison 53792-7375, USA. Kudsk@surgery.wisc.edu
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Kudsk
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Tolley
authors.forename: R Chance
authors.initials: RC
authors.lastname: DeWitt
authors.forename: Peter G
authors.initials: PG
authors.lastname: Janu
authors.forename: Ashley P
authors.initials: AP
authors.lastname: Blackwell
authors.forename: Stephanie
authors.initials: S
authors.lastname: Yeary
authors.forename: Brock K
authors.initials: BK
authors.lastname: King
mesh_terms: D015331:Cohort Studies; D013505:Digestive System Surgical Procedures / Q000009:adverse effects* / Q000401:mortality; D017558:Elective Surgical Procedures / Q000009:adverse effects* / Q000401:mortality; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D008875:Middle Aged; D009752:Nutritional Status / Q000502:physiology*; D018529:Nutritional Support / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000097:blood* / Q000209:etiology*; D011300:Preoperative Care; D012189:Retrospective Studies; D012307:Risk Factors; D012709:Serum Albumin / Q000032:analysis*; D013997:Time Factors
chemical_list: D012709:Serum Albumin