Is hypoalbuminemia associated with an increased risk of anastomosis dehiscence?

From the Guidelines

Hipoalbuminemia is associated with an increased risk of anastomosis dehiscence, as evidenced by recent studies. The most recent and highest quality study, published in 2021, suggests that hypoalbuminemia is a clear surgical risk factor, reflecting disease-associated catabolism and disease severity rather than undernutrition 1. This association is particularly important in colorectal, esophageal, and gastric surgeries where anastomotic complications can lead to serious morbidity and mortality.

Key Findings

• Hypoalbuminemia is associated with a higher risk of postoperative intra-abdominal sepsis, as noted in the 2019 British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1.
• The ESPEN practical guideline: clinical nutrition in surgery, published in 2021, defines severe nutritional risk, which includes serum albumin levels below 30 g/L, and emphasizes the importance of nutritional support in patients with malnutrition 1.
• A 2022 study published in the World Journal of Emergency Surgery recommends routine preoperative nutritional screening and nutritional supplementation for malnourished patients to reduce the risk of postoperative complications, including anastomotic leaks 1.

Clinical Implications

• Preoperative albumin levels should be assessed and optimized when possible before elective surgeries involving anastomoses.
• Correction of hypoalbuminemia may involve nutritional support through enteral or parenteral nutrition for 7-10 days preoperatively in severely malnourished patients.
• The mechanism behind this association relates to albumin's crucial role in wound healing, tissue repair, and maintaining oncotic pressure.
• Low albumin levels impair collagen synthesis and deposition at the anastomotic site, reduce tissue perfusion and oxygenation, and diminish the body's ability to mount an effective inflammatory response to heal the surgical connection.

Recommendations

• Patients with hypoalbuminemia should receive nutritional support prior to surgery to reduce the risk of anastomotic dehiscence.
• Nutritional screening should be performed preoperatively to identify patients at risk of malnutrition and anastomotic complications.
• A multidisciplinary approach, including dietitians and surgeons, is essential to optimize nutritional support and reduce the risk of postoperative complications.

From the Research

Association between Hypoalbuminemia and Anastomosis Dehiscence

• Hypoalbuminemia has been studied as a potential risk factor for anastomosis dehiscence in various surgical procedures 2, 3, 4, 5, 6.
• A study published in the International Journal of Colorectal Disease found that preoperative hypoalbuminemia was not a reliable marker for anastomotic leakage risk in patients undergoing elective colorectal surgery as part of an enhanced recovery after surgery (ERAS) program 2.
• However, other studies have reported an association between hypoalbuminemia and increased risk of anastomotic dehiscence. For example, a study published in the American Journal of Surgery found that hypoalbuminemia was an independent predictor of overall complications and 30-day mortality in patients undergoing major surgical procedures 3.
• A study published in Gastroenterology Report found that preoperative hypoalbuminemia was associated with an increased risk of intra-abdominal septic complications after primary anastomosis for Crohn's disease 4.
• Another study published in the Asian Journal of Surgery found that lower early postoperative serum albumin levels were a potentially valuable indicator of anastomotic leakage in colorectal cancer patients undergoing curative surgery 5.
• A study published in Digestive Surgery found that hypoalbuminemia was a significant risk factor for anastomotic disruption after emergent small bowel surgery 6.

Key Findings

• Hypoalbuminemia may be associated with an increased risk of anastomosis dehiscence in certain surgical procedures, but the evidence is not consistent across all studies 2, 3, 4, 5, 6.
• The association between hypoalbuminemia and anastomosis dehiscence may depend on various factors, including the type of surgery, patient population, and presence of other risk factors 3, 4, 5, 6.
• Further research is needed to fully understand the relationship between hypoalbuminemia and anastomosis dehiscence and to identify potential strategies for reducing the risk of anastomotic complications in patients with hypoalbuminemia 2, 3, 4, 5, 6.