European Journal of Cardiovascular Medicine

Wound healing is a complex physiological process influenced by multiple systemic and local factors, with nutritional status playing a pivotal role [3]. Patients undergoing major gastrointestinal (GI) surgeries are particularly vulnerable to nutritional deficiencies because of pre-existing illness, altered intake, and the catabolic stress imposed by surgery [2]. Malnutrition has been consistently associated with impaired immune responses, delayed collagen synthesis, reduced angiogenesis, and compromised tissue repair, leading to a higher incidence of surgical site infections (SSI), wound dehiscence, and delayed recovery [3,4].

Globally, the prevalence of malnutrition among surgical patients is estimated to range between 20% and 50%, with a higher burden observed in oncological and gastrointestinal procedures [1,4]. In low- and middle-income countries, including India, this problem is compounded by late presentation, anemia, and limited access to structured preoperative nutritional optimization [5]. Despite this, nutritional assessment remains underutilized in routine perioperative practice, and many patients undergo major abdominal surgery without appropriate correction of nutritional deficits [1,5].

Objective tools such as Nutritional Risk Screening (NRS-2002), Global Leadership Initiative on Malnutrition (GLIM) criteria, serum albumin, and Prognostic Nutritional Index (PNI) have been validated as reliable predictors of surgical outcomes [2,4]. However, there is limited prospective data exploring their specific role in predicting wound healing among GI surgical patients in the Indian context.

The present study was therefore undertaken to evaluate the impact of preoperative nutritional status on postoperative wound healing in patients undergoing major GI surgeries. By identifying the magnitude of risk and the specific nutritional parameters most strongly associated with adverse outcomes, this study aims to highlight the importance of routine nutritional screening and early intervention as part of comprehensive perioperative management.

Study Design and Setting
This was a prospective observational study conducted at the Department of Surgery, Father Colombo Institute of Medical Sciences, Warangal, in collaboration with Medicare General Hospital, Warangal. The study was carried out over a period of four months, from November 2024 to February 2025.

Study Population
A total of 100 patients who underwent major gastrointestinal (GI) surgeries during the study period were included. Adult patients (≥18 years) undergoing elective or emergency GI procedures, including colorectal, upper GI/hepatopancreatobiliary, and small bowel surgeries, were eligible. Patients with pre-existing chronic non-healing ulcers, those on long-term corticosteroids or immunosuppressive therapy, and those who declined consent were excluded.

Assessment of Nutritional Status
Preoperative nutritional status was evaluated within 24 hours of admission using standardized tools:

Nutritional Risk Screening (NRS-2002): A score ≥3 indicated nutritional risk.

GLIM Criteria: Applied for diagnosing malnutrition, with classification into moderate or severe grades.

Anthropometry: Body mass index (BMI) was calculated; BMI <18.5 kg/m² was considered underweight.

Biochemical Markers: Serum albumin <3.5 g/dL defined hypoalbuminemia.

Prognostic Nutritional Index (PNI): Derived from serum albumin and lymphocyte count; values <45 were considered low.

Sarcopenia: Assessed by calf circumference cut-offs based on Asian criteria.

Outcome Measures
Primary outcomes included the incidence of wound-related complications such as surgical site infections (superficial, deep, or organ/space), seroma, and wound dehiscence within 30 days of surgery. Secondary outcomes were time to complete epithelialization, duration of postoperative hospital stay, wound-related readmission, and re-operation.

Data Collection
Demographic details, comorbidities, type and approach of surgery (open vs. laparoscopic), operative duration, and contamination class were recorded. Postoperative wound assessment was performed daily until discharge and subsequently during follow-up visits.

Statistical Analysis
Data were entered in Microsoft Excel and analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) or median with interquartile range (IQR), while categorical variables were expressed as frequencies and percentages. Group comparisons were performed using chi-square or Fisher’s exact test for categorical variables and Mann–Whitney U test for continuous variables. Logistic regression was applied to identify independent predictors of wound complications. A p-value <0.05 was considered statistically significant.

Ethical Considerations
Ethical approval for the study was obtained from the Institutional Ethics Committee of Father Colombo Institute of Medical Sciences, Warangal. Written informed consent was obtained from all participants prior to enrolment.

A total of 100 patients undergoing major gastrointestinal surgeries were included in the study. The mean age of participants was 52 ± 14 years, with a male predominance (62%). Colorectal procedures accounted for 42% of cases, followed by upper gastrointestinal/hepatopancreatobiliary (38%) and small bowel/other surgeries (20%). Open surgery was performed in 58% of patients, while 42% underwent laparoscopic procedures. Nearly one-fourth of the cases were emergencies (27%). Diabetes (28%) and anemia (31%) were the most common comorbidities (Table 1).

Table 1. Baseline Characteristics of Study Participants (n = 100)

At admission, 46% of patients were identified as being at nutritional risk (NRS-2002 ≥ 3), while 34% fulfilled GLIM-defined malnutrition criteria, of which 22% were moderate and 12% severe. Hypoalbuminemia (<3.5 g/dL) was detected in 41% of patients. The median BMI was 22.4 kg/m², and 9% of patients were underweight. Nearly half of the study cohort (48%) had a low prognostic nutritional index (PNI < 45), and suspected sarcopenia was observed in 18% (Table 2).

Table 2. Nutritional Status at Admission

Wound-related complications were reported in 30% of patients. Superficial surgical site infection (SSI) was the most frequent complication (12%), followed by deep SSI (6%), wound dehiscence (6%), and seroma formation (9%). Organ/space SSI was less common (2%). The median time to complete epithelialization was 11 days (IQR 9–15), while the median postoperative hospital stay was 7 days (IQR 5–10). Eight patients (8%) required readmission for wound-related problems, and four patients (4%) underwent re-operation (Table 3).

Table 3. Wound Healing Outcomes

Figure 1: Wound Healing Outcomes

When stratified by nutritional status, malnourished patients had a significantly higher risk of wound complications compared with their well-nourished counterparts (47% vs. 22%, p = 0.004). Similarly, SSIs were more frequent among malnourished individuals (34% vs. 11%, p = 0.003), and wound dehiscence occurred in 12% compared with 2% in the well-nourished group (p = 0.041). Time to wound healing was prolonged in the malnourished group (median 14 vs. 10 days, p < 0.001), and hospital stay was correspondingly longer (median 9 vs. 6 days, p < 0.001). Although readmissions within 30 days were more common among malnourished patients (14% vs. 4%), this difference did not reach statistical significance (p = 0.079) (Table 4).

Table 4. Association of Malnutrition with Wound Complications

*Significant at p < 0.05