Is postoperative decrease of serum albumin an early predictor of complications after major abdominal surgery? A prospective cohort study in a European centre

  • Labgaa I, Joliat G-R, Kefleyesus A, Mantziari S, Schäfer, M, Demartines N, Hubner M.
  • BMJ Open 2017;7:e013966

The results from this prospective study indicate that an early rapid drop in postoperative serum albumin is a marker of surgical stress and could be an early predictor of patients at risk of postoperative complications.

There has been increasing interest in identifying biomarkers that track the stress response to surgery (Thorell et al., 1999; Kohl & Deutschman, 2006; Amar et al., 2007; Mantziari et al., 2015), and in their potential to identify patients at risk of developing postoperative complications.

Two such biomarkers already identified include C-reactive protein and procalcitonin. Although they are routinely used biomarkers in clinical practice, their usefulness is limited by their slow kinetics (Facy et al., 2016; Giaccaglia et al., 2016) with both markers only becoming useful about the fourth day after surgery.

In contrast, serum albumin is rapidly downregulated by inflammatory signals on the first postoperative day (Mantziari et al., 2015; Hübner et al., 2016;), with preliminary data suggesting an association between a rapid postoperative drop and outcomes after oesophageal, oral cancer, abdominal pancreatic, liver resection/transplant and cardiac surgeries (Ryan et al., 2007; Lee et al., 2011; 2015; Fujiwara et al., 2015; Sang et al., 2015; Labgaa et al., 2016).

This prospective study provided a head-to-head comparison of serum albumin with C-reactive protein and procalcitonin, with the aim of testing postoperative serum albumin drop as a marker of surgical stress and an early predictor of clinical outcomes (Figure 1).

Rapid decrease in serum albumin following surgery and correlation with patient outcomes

Figure 1. Rapid decrease in serum albumin following surgery and correlation with patient outcomes (Labgaa et al., 2017).

Successful preoperative measures already exist to attenuate the stress response to surgery include immunonutrition, enhanced recovery programmes and high-dose glucorticoids (Ljungqvist et al., 2005; de la Motte et al., 2014; Cerantola et al., 2015; Carli, 2015). Further research is needed to determine whether these options might also be effective postoperatively in calming the stress response once it has been triggered.

Background information about the many functions of albumin, as well as about the molecule itself, its distribution, metabolism and binding, can be found at:

Back to all publication digests



Amar D, Zhang H, Park B, Heerdt PM, Fleisher M, Thaler HT. Inflammation and outcome after general thoracic surgery. Eur J Cardiothorac Surg. 2007;32:431–4.

Carli F. Physiologic considerations of enhanced recovery after surgery (ERAS) programs: implications of the stress response, Can J Anaesth. 2015;62:110–19.

Cerantola Y, Hübner M, Grass F, Demartines N, Schäfer M. Immunonutrition in gastrointestinal surgery. Br J Surg. 2011;98(1):37–48.

de la Motte L, Kehlet H, Vogt K, Nielsen CH, Groenvall JB, Nielsen HB, et al. Preoperative methylprednisolone enhances recovery after endovascular aortic repair: a randomized, double-blind, placebo-controlled clinical trial. Ann Surg. 2014;260(3):540–8.

Facy O, Paquette B, Orry D, Binquet C, Masson D, Bouvier A, et al. Diagnostic accuracy of inflammatory markers as early predictors of infection after elective colorectal surgery: results from the IMACORS study. Ann Surg. 2016;263:961–6.

Fujiwara Y, Shiba H, Shirai Y, Iwase R, Haruki K, Furukawa K, et al. Perioperative serum albumin correlates with postoperative pancreatic fistula after pancreaticoduodenectomy. Anticancer Res. 2015;35:499–503.

Giaccaglia V, Salvi PF, Antonelli MS, Nigri G, Pirozzi F, Casagranda B, et al. Procalcitonin reveals early dehiscence in colorectal surgery: the PREDICT study. Ann Surg. 2016;263:967–72.

Hübner M, Mantziari S, Demartines N, Pralong F, Coti-Bertrand P, Schäfer M. Postoperative albumin drop is a marker for surgical stress and a predictor for clinical outcome: a pilot study. Gastroenterol Res Pract. 2016;2016:8743187. 

Kohl BA, Deutschman CS. The inflammatory response to surgery and trauma. Curr Opin Crit Care. 2006;12:325–32.

Labgaa I, Joliat GR, Demartines N, Hübner M. Serum albumin is an early predictor of complications after liver surgery. Dig Liver Dis. 2016;48:559–61.

Lee EH, Chin JH, Choi DK, Hwang BY, Choo SJ, Song JG, et al. Postoperative hypoalbuminemia is associated with outcome in patients undergoing off-pump coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth. 2011;25:462–8.

Lee JI, Kwon M, Roh JL, Choi JW, Choi SH, Nam SY, et al. Postoperative hypoalbuminemia as a risk factor for surgical site infection after oral cancer surgery. Oral Dis. 2015;21:178–84. 

Ljungqvist O, Nygren J, Soop M, Thorell A. Metabolic perioperative management: novel concepts. Curr Opin Crit Care. 2005;11(4):295–9.

Mantziari S, Hübner M, Coti-Bertrand P, Pralong F, Demartines N, Schäfer M. A novel approach to major surgery: tracking its pathophysiologic footprints. World J Surg. 2015;39:2641–51.

Ryan AM, Hearty A, Prichard RS, Cunningham A, Rowley SP, Reynolds JV. Association of hypoalbuminemia on the first postoperative day and complications following esophagectomy. J Gastrointest Surg. 2007;11:1355–60.

Sang BH, Bang JY, Song JG, Hwang GS. Hypoalbuminemia within two postoperative days is an independent risk factor for acute kidney injury following living donor liver transplantation: a propensity score analysis of 998 consecutive patients. Crit Care Med. 2015;43:2552–61.

Thorell A, Nygren J, Ljungqvist O. Insulin resistance: a marker of surgical stress. Curr Opin Clin Nutr Metab Care. 1999;2:69–78.

Login/ Register Maximise Minimise