Malnutrition is a prevalent and often underrecognized risk factor that significantly influences postoperative outcomes in patients undergoing major abdominal surgery. The physiological stress associated with surgery increases metabolic demands, and when compounded by inadequate nutritional reserves, it predisposes patients to a spectrum of adverse outcomes including infections, delayed wound healing, prolonged hospitalization, and mortality. Recent evidence reinforces the role of preoperative nutritional assessment in predicting surgical prognosis and guiding perioperative care strategies [1–3].

Kanemoto et al. demonstrated that poor preoperative nutritional status independently predicted higher rates of postoperative complications and longer recovery periods in abdominal surgery patients, underscoring the need for early identification of at-risk individuals [1]. Similarly, Wobith et al. highlighted the utility of the Global Leadership Initiative on Malnutrition (GLIM) criteria and advanced modalities like CT and bioelectrical impedance analysis (BIA) in objectively diagnosing malnutrition prior to surgery [2].

Classic studies such as those by Sungurtekin et al. established early links between malnutrition and increased surgical morbidity, particularly infectious and respiratory complications, affirming the biological plausibility of nutrition-related immunosuppression and catabolic imbalance [3]. Akula and Doctor further emphasized that even subclinical nutritional deficits can lead to unfavorable surgical outcomes, suggesting that comprehensive screening should be routine [4].

In resource-limited settings, Mambou Tebou et al. found similar associations, reinforcing the global relevance of preoperative nutritional care [5]. Moreover, Mignini et al. reported that nutritional optimization improved overall surgical outcomes, supporting integration of nutrition into perioperative protocols [6].

This study was designed to evaluate the nutritional status of patients undergoing major abdominal surgery and to analyze its impact on early postoperative outcomes, with the goal of reinforcing the importance of routine nutritional screening and targeted interventions in surgical practice.

Study Design and Setting

This was a prospective observational study conducted over a 3-month period from January 10th to April 10th at the Department of Surgical Gastroenterology and General Surgery, Government Medical College (GMC), Anantapuramu, a tertiary care teaching hospital located in Andhra Pradesh, India.

Study Population

The study included 200 adult patients (aged ≥18 years) undergoing elective major abdominal surgery during the study period. Major abdominal surgeries included gastrointestinal resections, hepatobiliary surgeries, abdominal wall reconstructions, and complex hernia repairs. Patients admitted for minor procedures, emergency surgeries, or with terminal illness were excluded.

Data Collection and Nutritional Assessment

Preoperative nutritional status was assessed using three validated tools:

Subjective Global Assessment (SGA): Patients were classified as well-nourished (SGA A), moderately malnourished (SGA B), or severely malnourished (SGA C) based on clinical criteria including weight loss, dietary intake, gastrointestinal symptoms, functional status, and physical examination.

Body Mass Index (BMI): Calculated as weight (kg)/height² (m²) and categorized per WHO standards: underweight (<18.5 kg/m²), normal (18.5–24.9 kg/m²), and overweight/obese (≥25 kg/m²).

Serum Albumin: Measured preoperatively, with <3.0 g/dL indicating hypoalbuminemia.

Outcome Measures

• Postoperative outcomes monitored included:
• Surgical site infections
• Wound dehiscence
• Respiratory complications
• Length of hospital stay (>10 days considered prolonged)
• Reoperation rates
• 30-day mortality

All complications were classified using standard definitions from CDC and Clavien-Dindo grading for surgical morbidity.

Statistical Analysis

Data were analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY). Categorical variables were expressed as frequencies and percentages; continuous variables as mean ± standard deviation (SD). Associations between nutritional status and postoperative outcomes were tested using the Chi-square test or Fisher’s exact test for categorical variables. Multivariate logistic regression was performed to identify independent predictors of adverse outcomes. A p-value <0.05 was considered statistically significant.

Ethical Considerations

Necessary permissions were taken from concerned authorities before starting the study. Written informed consent was obtained from all participants prior to enrollment.

A total of 200 patients undergoing major abdominal surgery were enrolled in the study. The mean age of the cohort was 54.6 ± 12.4 years, with a predominance of males (60%). The most common indications for surgery were gastrointestinal malignancies (42%), followed by complicated hernias (25%), intestinal obstruction (22%), and hepatobiliary or other abdominal conditions (11%) (Table 1).

Table 1: Demographic and Clinical Characteristics (n = 200)

Nutritional Status

Nutritional assessment using the Subjective Global Assessment (SGA) categorized 39% of patients as well-nourished (SGA A), 43% as moderately malnourished (SGA B), and 18% as severely malnourished (SGA C). Based on body mass index (BMI), 29% were underweight (<18.5 kg/m²), 46% had normal BMI (18.5–24.9 kg/m²), and 25% were overweight or obese (>25 kg/m²). Serum albumin levels were below 3.0 g/dL in 41% of patients, indicating hypoalbuminemia, while 59% had levels ≥3.0 g/dL (Table 2).

Table 2: Nutritional Status Distribution among Patients

Postoperative Complications and Nutritional Status

Postoperative morbidity was significantly higher among malnourished patients (SGA B and C) compared to well-nourished individuals. Surgical site infections occurred in 30.3% of malnourished patients versus 11.5% in the well-nourished group (p < 0.001). Similarly, the incidence of wound dehiscence (9.8% vs. 2.6%, p = 0.04), respiratory complications (17.2% vs. 7.7%, p = 0.03), and prolonged hospital stay exceeding 10 days (48.4% vs. 17.9%, p < 0.001) was significantly higher in malnourished individuals. Mortality within 30 days post-surgery was also notably greater in this group (6.6% vs. 1.3%, p = 0.04), although the rate of reoperation did not reach statistical significance (Table 3).

Table 3: Postoperative Complications by Nutritional Status

Multivariate Analysis

On logistic regression analysis adjusting for age, sex, and surgical indication, both malnutrition (SGA B or C) and hypoalbuminemia emerged as independent predictors of adverse outcomes. Malnourished patients had a 2.6-fold increased risk of developing postoperative complications (adjusted OR: 2.6; 95% CI: 1.5–4.8; p < 0.001), and those with serum albumin <3.0 g/dL had a 2.4-fold increased risk (adjusted OR: 2.4; 95% CI: 1.4–4.2; p = 0.002) (Table 4).

Table 4: Multivariate Logistic Regression – Nutritional Predictors of Poor Outcome

This study reaffirms the critical role of nutritional status as a determinant of postoperative outcomes in patients undergoing major abdominal surgery. A significant proportion of the study cohort was identified as malnourished, and these patients experienced higher rates of postoperative complications, including surgical site infections, respiratory complications, prolonged hospital stays, and 30-day mortality. These findings are consistent with multiple international and regional studies emphasizing the negative impact of poor nutritional reserves on surgical recovery.

Hussen et al. conducted a similar observational study in a resource-constrained setting and reported that preoperative malnutrition significantly increased the risk of postoperative infections and delayed wound healing, reinforcing the global relevance of nutritional screening regardless of healthcare infrastructure [7]. Similarly, Leide da Silva Nunes et al. found that nutritional deficits were associated with prolonged postoperative recovery times and higher complication rates in abdominal surgery patients [11].

Importantly, emerging evidence also supports the proactive use of nutritional support. A recent systematic review by Loon et al. demonstrated that targeted preoperative nutritional interventions improved surgical outcomes, particularly in gastrointestinal procedures, and reduced morbidity across diverse patient populations [8]. These findings align with the ESPEN-endorsed recommendations, which advocate for structured nutritional screening and supplementation in high-risk surgical patients [10].

Furthermore, the NURIMAS Liver study protocol by Probst et al. highlighted the prognostic value of validated nutritional scoring systems in predicting postoperative risks, thereby supporting the integration of objective assessments into perioperative planning [9]. In the context of chronic inflammatory diseases, Yamamoto et al. showed that malnutrition remained a significant risk factor for complications even among patients receiving biologic therapy, emphasizing its independent effect across different clinical backgrounds [12].

Together, these findings underscore the necessity of recognizing malnutrition as a modifiable preoperative risk factor. Incorporating standardized nutritional assessments and early interventions can not only enhance clinical outcomes but also reduce healthcare burdens by shortening hospital stays and minimizing postoperative morbidity.

This study underscores the high prevalence of malnutrition among patients undergoing major abdominal surgery and its significant association with adverse postoperative outcomes. Nutritional deficits, as identified by SGA, low BMI, and hypoalbuminemia, independently predicted increased rates of complications, prolonged hospital stay, and mortality. These findings emphasize the need for mandatory preoperative nutritional screening and early intervention as part of routine surgical care. Integrating nutritional assessment into the perioperative pathway can improve clinical outcomes, reduce healthcare burden, and enhance recovery. Future research should focus on the benefits of targeted nutritional optimization or prehabilitation strategies in malnourished surgical patients to further validate these findings.

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