Malnutrition and postoperative complications in abdominal surgery

We read with great interest the article by Hennessey et al 1 who studied retrospectively the relationship between preoperative serum albumin and surgical site infection(SSI) in a heterogeneous population of 524 patients undergoing gastrointestinal surgery.A total of 105 patients developed SSI and among them hypoalbuminemia (>30 mg/dL) was significantly associated, both at univariate and multivariate analysis, with the development of SSI, deeper SSI and prolonged inpatient stay. It is well known that malnutrition is a significant risk factor of postoperative complications in major abdominal surgery. Disclosure: The authors declare that they have nothing to disclose. DOI: 10.1097/SLA.0b013e3182306457 However, in the last 3 decades we have assisted to an impressive improvement of anaesthetic and surgical techniques and in an amelioration of postoperative patient management that have led to a reduction of postoperative morbidity and mortality. At the same time, some recent evidence suggests that being overweight and obesity, rather than malnutrition, are significant risk factors of postoperative complications in major abdominal surgery. Indeed, in 2008 we published the results of a prospective study that evaluated the incidence of mortality and major and minor postoperative complications in patients who underwent surgery for gastric cancer between 2000 and 2006. In this study, we stratified patients according to the preoperative percentage weight loss (0%–5%, 5.1%–10%, >10%) and serumalbumin levels < 3.0 g/dL; 3.0–3.4 g/dL; ≥ 3.5 g/dL). Interestingly, the rate of major infectious, major non-infectious and minor infectious (as SSI) postoperative complications was similar in patients with serum albumin 8.1%, respectively); between 3.0 and 3.4 (8.8%, 13.3%, 17.7%, respectively) or ≥ 3.5 g/dL (10.5%, 7.9%, 8.7%, respectively). It is difficult to explain the difference between our study and that of Hennessey et al Indeed, the study of Hennessey et al was retrospective and it is unknown if the surgeons or the attending doctors who made the diagnosis of SSI in each case were blinded to the status of serum albumin. In addition, the population studied by Hennessey et al was extremely heterogeneous, including patients who underwent elective or urgent operations on the gastrointestinal tract including stomach, duodenum, gallbladder, small intestine and colon and rectum, whereas we studied only patients undergoing gastric surgery. It has been shown that malnutrition does not re-enter in the risk factors predictive of postoperative morbidity in surgery for malignant gastric tumors. It seems that role of hypoalbuminemia in the development of SSI varies according to the type of disease, to the type of surgery and to the characteristics of patients.