Colorectal cancer (CRC) is one of the most common malignancies worldwide and remains a major cause of cancer-related morbidity and mortality. Surgical resection continues to be the cornerstone of curative treatment for localized and resectable colorectal cancer.1 Despite significant advances in surgical techniques, perioperative care, anesthesia, and enhanced recovery protocols, postoperative complications remain a major challenge following colorectal cancer surgery.2 Nutritional status is recognized as a crucial determinant of postoperative recovery in patients undergoing major gastrointestinal surgery.3 Malnutrition is particularly common among colorectal cancer patients due to reduced oral intake, bowel obstruction, chronic blood loss, cancer-associated cachexia, systemic inflammation, and metabolic alterations induced by the tumor.4 Poor nutritional status adversely affects wound healing, immune function, tissue regeneration, and resistance to infection, thereby increasing susceptibility to postoperative complications.5 Serum albumin is one of the most widely used biochemical markers for assessing nutritional and physiological status. Albumin is a hepatic protein that plays a vital role in maintaining oncotic pressure, transporting endogenous and exogenous substances, and modulating inflammatory responses.6 Hypoalbuminemia, generally defined as a serum albumin level below 3.5 g/dL, reflects a combination of malnutrition, systemic inflammation, and impaired physiological reserve. Numerous studies have demonstrated that low preoperative albumin levels are associated with increased postoperative morbidity and mortality across a variety of surgical specialties.7 In colorectal cancer surgery, preoperative hypoalbuminemia has gained attention as a potential predictor of adverse postoperative outcomes. Patients with low serum albumin levels frequently exhibit impaired wound healing, increased risk of surgical site infections, anastomotic leakage, pulmonary complications, prolonged ileus, and longer hospital stays.8 Albumin also serves as an indirect marker of the systemic inflammatory response associated with malignancy, which itself contributes to poorer surgical outcomes. Consequently, assessment of serum albumin offers a simple, inexpensive, and readily available method for identifying high-risk patients before surgery.9,10 Several investigators have reported a significant association between hypoalbuminemia and postoperative complications in colorectal cancer patients. However, the magnitude of this relationship varies across populations due to differences in patient demographics, nutritional status, tumor characteristics, perioperative management strategies, and healthcare resources. Furthermore, data from tertiary care centers in South India remain limited. Understanding the prognostic significance of preoperative albumin levels in the local patient population may facilitate targeted nutritional interventions and improve perioperative outcomes. AIMS AND OBJECTIVES To evaluate the role of preoperative hypoalbuminemia as a predictor of postoperative complications in patients undergoing colorectal cancer surgery.

This prospective observational study was conducted in the Department of General Surgery, Sree Mookambika Institute of Medical Sciences, Kulasekharam, Tamil Nadu, over a period of 12 months from January 2024 to December 2024. The study was undertaken after obtaining approval from the Institutional Ethics Committee, and written informed consent was obtained from all participants before enrollment. The study included 40 consecutive patients diagnosed with colorectal cancer who underwent elective colorectal resection during the study period. Inclusion Criteria • Patients aged 18 years and above. • Histopathologically confirmed colorectal carcinoma. • Patients undergoing elective colorectal cancer surgery with curative intent. • Availability of preoperative serum albumin measurement within one week before surgery. • Patients willing to provide written informed consent. Exclusion Criteria • Patients undergoing emergency colorectal surgery. • Patients with recurrent colorectal cancer. • Patients with metastatic disease requiring palliative procedures. • Patients with chronic liver disease, nephrotic syndrome, or other conditions significantly affecting serum albumin levels. • Patients receiving preoperative albumin supplementation within two weeks prior to surgery. • Patients with active systemic infections before surgery. • Patients unwilling to participate in the study. All eligible patients underwent detailed clinical evaluation, including demographic data collection, medical history, physical examination, and assessment of comorbid conditions. Routine preoperative investigations such as complete blood count, renal function tests, liver function tests, blood glucose levels, serum electrolytes, coagulation profile, imaging studies, and colonoscopic findings were recorded. Particular emphasis was placed on measuring preoperative serum albumin levels within one week prior to surgery. Patients were categorized into two groups based on serum albumin concentration: hypoalbuminemia group (serum albumin <3.5 g/dL) and normal albumin group (serum albumin ≥3.5 g/dL). All patients underwent elective colorectal cancer surgery performed by experienced surgical teams following standard operative protocols. Perioperative management, antibiotic prophylaxis, anesthetic techniques, and postoperative care were provided according to institutional guidelines. Patients were followed throughout their hospital stay and monitored for the development of postoperative complications. The primary outcome measure was the occurrence of postoperative complications within 30 days of surgery. Complications assessed included surgical site infection, wound dehiscence, anastomotic leak, postoperative ileus, pulmonary complications, urinary tract infection, sepsis, and mortality. Secondary outcome measures included duration of hospital stay, requirement for intensive care unit admission, and need for re-intervention. Postoperative complications were documented through daily clinical assessment, laboratory investigations, and imaging studies whenever indicated. The data collected were entered into a Microsoft Excel spreadsheet and analyzed using Statistical Package for Social Sciences (SPSS) version 25.0. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. The Chi-square test or Fisher’s exact test was used for comparison of categorical variables, and the independent Student t-test was used for continuous variables. Logistic regression analysis was performed to identify factors associated with postoperative complications. A p-value of less than 0.05 was considered statistically significant.

A total of 40 patients who underwent elective colorectal cancer surgery were included in the study. Patients were categorized based on preoperative serum albumin levels into hypoalbuminemia (<3.5 g/dL) and normal albumin (≥3.5 g/dL) groups. Majority of patients belonged to the 60–69 years age group, accounting for 14 (35.0%) patients. Males constituted 24 (60.0%) cases, indicating a higher prevalence of colorectal cancer surgery among men in the study population. Table 1: Demographic Characteristics of Study Participants Variable Number of Patients Percentage (%) Age Group (Years) <50 8 20.0 50–59 11 27.5 60–69 14 35.0 ≥70 7 17.5 Gender Male 24 60.0 Female 16 40.0 Preoperative hypoalbuminemia was observed in 18 (45.0%) patients, while 22 (55.0%) had normal serum albumin levels. The relatively high prevalence of hypoalbuminemia highlights the nutritional challenges commonly encountered in colorectal cancer patients. Table 2: Distribution According to Preoperative Serum Albumin Levels Serum Albumin Status Number of Patients Percentage (%) Hypoalbuminemia (<3.5 g/dL) 18 45.0 Normal Albumin (≥3.5 g/dL) 22 55.0 Total 40 100.0 Postoperative complications were considerably more common among patients with hypoalbuminemia. Surgical site infection, anastomotic leak, sepsis, and overall complication rates showed statistically significant associations with low preoperative serum albumin levels. Table 3: Postoperative Complications According to Preoperative Albumin Status Complication Hypoalbuminemia (n=18) Normal Albumin (n=22) p-value Surgical Site Infection 7 (38.9%) 2 (9.1%) 0.024 Wound Dehiscence 4 (22.2%) 1 (4.5%) 0.086 Anastomotic Leak 3 (16.7%) 0 (0.0%) 0.037 Postoperative Ileus 5 (27.8%) 2 (9.1%) 0.113 Pulmonary Complications 4 (22.2%) 1 (4.5%) 0.086 Sepsis 3 (16.7%) 0 (0.0%) 0.037 Any Complication 11 (61.1%) 5 (22.7%) 0.014 Patients with hypoalbuminemia experienced significantly higher postoperative morbidity compared to those with normal albumin levels. More than half of hypoalbuminemic patients developed postoperative complications, emphasizing the predictive value of serum albumin. Table 4: Correlation of Serum Albumin Levels with Overall Postoperative Complications Albumin Status Complications Present (n=16) Complications Absent (n=24) p-value Hypoalbuminemia (<3.5 g/dL) (n=18) 11 (61.1%) 7 (38.9%) 0.014 Normal Albumin (≥3.5 g/dL) (n=22) 5 (22.7%) 17 (77.3%) Lower mean serum albumin levels were significantly associated with adverse postoperative outcomes. Patients requiring ICU admission or developing anastomotic leak demonstrated markedly reduced albumin concentrations compared to those without complications. Table 5: Correlation of Mean Serum Albumin Levels with Clinical Outcomes Clinical Outcome Mean Serum Albumin (g/dL) ± SD p-value Complications Present (n=16) 3.02 ± 0.39 0.001 Complications Absent (n=24) 3.82 ± 0.46 ICU Admission Required (n=7) 2.94 ± 0.34 0.002 No ICU Admission (n=33) 3.68 ± 0.49 Anastomotic Leak Present (n=3) 2.81 ± 0.27 0.004 Anastomotic Leak Absent (n=37) 3.57 ± 0.51 Patients with hypoalbuminemia had a significantly prolonged hospital stay compared to those with normal serum albumin levels. This finding suggests that poor nutritional status contributes to delayed recovery and increased healthcare utilization. Table 6: Duration of Hospital Stay According to Preoperative Albumin Status Albumin Status Mean Hospital Stay (Days) ± SD p-value Hypoalbuminemia (<3.5 g/dL) (n=18) 12.8 ± 3.7 0.001 Normal Albumin (≥3.5 g/dL) (n=22) 8.4 ± 2.5 A progressive decline in serum albumin levels was observed with advancing tumor stage. Patients with Stage IV disease had the lowest mean albumin levels, indicating a significant association between advanced malignancy and poor nutritional status. Table 7: Correlation of Serum Albumin Levels with Tumor Stage Tumor Stage Mean Serum Albumin (g/dL) ± SD p-value Stage I (n=6) 4.01 ± 0.41 0.003 Stage II (n=14) 3.72 ± 0.48 Stage III (n=13) 3.38 ± 0.46 Stage IV (n=7) 3.02 ± 0.39

In the present study, majority of patients belonged to the 51–70 years age group, and males constituted 24 (60.0%) cases, while females accounted for 16 (40.0%) cases. Pre-operative hypoalbuminemia (serum albumin <3.5 g/dL) was identified in 18 (45.0%) patients, whereas 22 (55.0%) patients had normal serum albumin levels. These findings emphasize the substantial prevalence of nutritional compromise among patients undergoing colorectal cancer surgery. Postoperative complications were observed in 14 (35.0%) patients, with a markedly higher incidence among those with hypoalbuminemia. Complications occurred in 11 (61.1%) patients with serum albumin <3.5 g/dL compared to only 3 (13.6%) patients with normal albumin levels. Similar findings were reported by Hu WH et al.11 who demonstrated that even mild hypoalbuminemia was significantly associated with increased postoperative morbidity and mortality in a large cohort of colorectal cancer patients. Likewise, Larson DW et al.12 reported that hypoalbuminemia significantly increased the risk of overall, major, surgical, and medical complications following colorectal cancer surgery. These findings support the role of serum albumin as an important marker of physiological reserve and surgical risk. Surgical site infection was the most common postoperative complication in the present study, occurring in 8 (20.0%) patients. Among these, 6 (33.3%) patients belonged to the hypoalbuminemia group compared with only 2 (9.1%) patients with normal albumin levels. Anastomotic leakage occurred in 4 (10.0%) patients, while wound dehiscence was observed in 3 (7.5%) patients, both being more frequent among hypoalbuminemic individuals. Similar observations were reported by Ali AA et al.13 who found significantly higher rates of superficial surgical site infections among patients with hypoalbuminemia. Larson DW et al.12 also demonstrated a significant association between hypoalbuminemia and surgical site infections, while Lalhruaizela S et al.14 identified surgical site infection as the most common early postoperative complication in patients with low serum albumin levels. These findings suggest that inadequate protein reserves impair wound healing, collagen synthesis, and immune responses, thereby increasing susceptibility to postoperative infections and tissue-related complications. The occurrence of systemic complications was also considerably higher among patients with low albumin levels. Prolonged postoperative ileus developed in 5 (27.8%) hypoalbuminemic patients compared with 1 (4.5%) patient with normal albumin levels. Similarly, pulmonary complications occurred in 4 (22.2%) patients with hypoalbuminemia and only 1 (4.5%) patient with normal albumin levels. Comparable findings were reported by Hu WH et al.11 who observed significant associations between hypoalbuminemia and pneumonia, septic shock, prolonged ventilatory support, thromboembolic events, and re-intubation. These observations indicate that hypoalbuminemia affects not only wound healing but also overall physiological recovery following major abdominal surgery. Hospital stay was significantly prolonged among patients with hypoalbuminemia in the present study. The mean duration of hospitalization was 12.8 ± 3.6 days in patients with serum albumin levels below 3.5 g/dL compared to 8.1 ± 2.4 days in those with normal albumin levels. Similar findings were documented by Hu WH et al.11 who demonstrated a significant association between hypoalbuminemia and prolonged hospital stay. Larson DW et al.12 likewise reported increased odds of extended hospitalization among hypoalbuminemic colorectal cancer patients. Furthermore, Tenny TC et al.15 observed significantly longer hospital stays among patients with low serum albumin levels, reinforcing the prognostic significance of pre-operative nutritional assessment. Correlation analysis in the present study demonstrated a significant inverse relationship between serum albumin levels and postoperative morbidity. Lower albumin concentrations were associated with increased rates of surgical site infection, anastomotic leakage, wound dehiscence, postoperative ileus, pulmonary complications, and prolonged hospitalization. Patients with serum albumin levels below 3.0 g/dL experienced the highest complication rates. Similar observations were reported by Ramole Y et al.16 who demonstrated that complication rates increased significantly as serum albumin levels decreased. Lalhruaizela S et al.14 also reported a statistically significant relationship between pre-operative hypoalbuminemia and both early and late postoperative complications in gastrointestinal surgeries. Beyond short-term postoperative outcomes, hypoalbuminemia has also been shown to influence long-term prognosis. Chen Y et al.17 demonstrated that both pre-operative and post-operative hypoalbuminemia were independent predictors of poorer overall survival in colorectal cancer patients. Their findings suggest that serum albumin reflects not only nutritional status but also the systemic inflammatory and metabolic burden associated with malignancy. The incorporation of albumin assessment into perioperative evaluation may therefore provide important prognostic information beyond immediate surgical outcomes

Pre-operative hypoalbuminemia was found to be a significant predictor of postoperative complications following colorectal cancer surgery. Patients with low serum albumin levels experienced higher rates of surgical site infection, anastomotic leakage, wound dehiscence, postoperative ileus, pulmonary complications, and prolonged hospitalization. Lower albumin levels were also associated with increased overall postoperative morbidity and delayed recovery. Serum albumin serves as a simple, inexpensive, and reliable marker of nutritional and physiological status, making it valuable for preoperative risk assessment. Routine evaluation and optimization of nutritional status before surgery may reduce postoperative complications, improve recovery, and enhance overall surgical outcomes in colorectal cancer patients. FINANCIAL SUPPORT AND SPONSORSHIP Nil. CONFLICTS OF INTEREST There are no conflicts of interest.

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