Background: Despite reports of adverse outcomes for patients with low serum albumin levels undergoing general surgical operations, this association has not been investigated in ileoanal pouch surgery (IPAA). We investigated the effect of preoperative albumin on early and late outcomes after IPAA in ulcerative colitis (UC).
Methods: Data of patients prospectively accrued into a pouch database were evaluated to determine the association between preoperative albumin and outcomes after IPAA. Preoperative and perioperative factors and 30-day complications for patients with albumin of ≤3.0, 3.1-3.5 and >3.5 g/dl were compared. Chi-squared, Fisher’s exact tests, Kaplan-Meier method and Cox multivariable statistical analyses were performed.
Results: 1185 UC patients (44% female) had documented preoperative serum albumin. Comparing patients with albumin <3.5 (n= 139) and >3.5 (n= 1046), there was no difference in gender (p=0.98), ASA score (p=0.13), comorbidity (p=0.92) and use of defunctioning ileostomy (p=0.09). The group with albumin <3.5 was older (p=0.004), and received greater intraoperative transfusion (p=0.01). A greater proportion of patients in the <3.5 group had predominant surgical indication as failed medical therapy and steroid dependence (p=0.001), perioperative steroid use (p=0.001) and underwent proctocolectomy at IPAA (p=0.001). Despite this, 30-day complications including wound infection (p=0.2), sepsis (p= 0.4), anastomotic separation (p=1) and long-term pouch-failure (p=0.9) and pouchitis (p=0.73) were similar. Estimated 5-year mortality risk was significantly greater for the <3.5 albumin group (6.2% vs. 1.4%, p=0.02). Age (p=0.001), steroid use (p=0.012), and albumin of <3.5 were associated with long-term mortality on multivariate analysis. Comparison of the <3.0 and >3.1 group did not show any difference in 30-day postoperative complications or long-term outcomes.
Conclusion: Serum albumin levels <3.5 g/dl are seen in patients who are ill and are associated with long term mortality. Proctocolectomy in these patients may be inevitable. When performing IPAA, due care directed to surgical technique and decision-making prevents adverse early outcomes.