The Effects of Malnutrition and Refeeding on Perioperative Wound Complications in Surgical Patients With Eating Disorders: A Narrative Review.

Anorexia nervosa (AN) and bulimia nervosa (BN) are eating disorders (EDs) with the highest mortality rate of psychiatric illnesses and medical complications, often due to protein-energy malnutrition and micronutrient deficiencies, leading to poor long-term outcomes. Patients with EDs undergo changes in nutritional status that manifest as decreased skin tensile strength, impaired immune function, reduced collagen production, and disrupted electrolyte and fluid balance, thereby increasing the risk of surgical site infections (SSIs), pressure ulcers (PUs), refeeding syndrome (RS), and edema/refeeding edema (RE). This narrative review aims to describe evidence regarding how malnutrition in patients with EDs impairs perioperative wound healing and propose clinical guidelines to reduce complications. The Web of Science, PubMed, and Scopus databases were searched using terms related to EDs and malnutrition. Peer-reviewed studies were included if they addressed malnutrition in the context of EDs, discussed compromised tissue repair, examined associations between malnutrition and perioperative outcomes, or evaluated nutritional interventions for recovery in malnourished hospital patients. Excluded were opinion pieces and writing that lacked ED wound-healing outcomes. The main findings of the 31 included studies are as follows. One, chronic malnutrition in AN and BN is associated with dermatological manifestations, such as xerosis and ecchymosis, reflecting reduced dermal strength and systemic dysfunction. Two, laboratory findings, including hypoalbuminemia (<3.5 g/dL), vitamin C deficiency, zinc deficiency, and electrolyte imbalances, are associated with impaired tissue healing and increased risk of infection in this patient population, with hypoalbuminemia a significant indicator of SSI risk. Vitamin C deficiency is associated with impaired collagen cross-linking; supplementation has been linked to accelerating recovery in general wound-healing populations. Zinc deficiency impairs keratinocyte migration and perioperative immunity by reducing CD4+ and CD8+ T-cell production, compounding the risks of RS, SSI, and PU. Three, refeeding malnourished patients carries physiological risks such as RS and RE mediated by electrolyte imbalances and unregulated fluid shifts. Uncontrolled RE is associated with compromised skin turgor, increased tension on sutures, impaired collagen synthesis, and a markedly increased risk of wound dehiscence, PU, and SSI. The incidence of PU in high-risk surgical patients can be reduced with targeted oral nutritional supplementation. Patients with EDs requiring surgical intervention need specific perioperative care to ensure optimal health outcomes. Preoperative nutrition screenings are essential, and postoperative cautious refeeding plans should include strict electrolyte and fluid intake monitoring. Multidisciplinary coordination, as the standard of care, may help reduce complications such as SSI, PU, and RS and support patients' wound-healing efforts. Future work should reduce the gap in research for this population by testing and developing a standardized nutritional protocol and effective monitoring strategies tailored to eating disorder patients undergoing surgery. Without streamlined care criteria, clinicians must rely on general refeeding guidelines that do not address the unique needs of this patient population, potentially leading to further physiological complications.