Association among preoperative comorbidities, targeted nursing interventions, and postoperative recovery in patients undergoing total gastrectomy for gastric cancer

Abstract

BACKGROUND

Patients undergoing total gastrectomy for gastric cancer (GC) often have varying degrees of preoperative comorbidities that can influence perioperative care and postoperative recovery. However, the relationships among comorbidity severity, perioperative nursing processes, and early recovery outcomes remain unclear.

AIM

To examine the associations among preoperative comorbidities, perioperative nursing process indicators, and postoperative recovery after total gastrectomy for GC.

METHODS

This retrospective cohort study included data from patients who underwent total gastrectomy for GC. Perioperative nursing process indicators included preoperative waiting time, times to first ambulation, oral intake, and nasogastric tube removal. Postoperative recovery endpoints included postoperative recovery time and length of hospital stay.

RESULTS

Higher comorbidity severity was associated with worse baseline nutritional parameters and a higher American Society of Anesthesiologists physical status. Patients with severe comorbidities tended to experience delayed perioperative nursing events. After adjustment, an inverse association was observed in the fully adjusted model. Multivariate analysis revealed that the time to first oral intake was an independent predictor of delayed recovery.

CONCLUSION

Severe preoperative comorbidities were associated with delayed perioperative nursing milestones but were not associated with delayed postoperative recovery in the expected positive direction after adjustment. Time to first oral intake exhibited a strong independent association with delayed recovery.

Key Words: Gastric cancer; Total gastrectomy; Preoperative comorbidities; Nursing interventions; Postoperative recovery

Core Tip: This retrospective cohort study investigates the relationship between preoperative comorbidity severity, perioperative nursing processes, and early recovery outcomes in 174 gastric cancer patients undergoing total gastrectomy. While higher comorbidity severity correlated with delayed key nursing events (e.g., time to first oral intake and ambulation), it was not an independent predictor of delayed postoperative recovery after multivariate adjustment. The analysis identified time to first oral intake as a significant independent predictor of delayed recovery.

INTRODUCTION

Gastric cancer (GC) continues to be a significant contributor to the global cancer burden, with recent estimates indicating that it contributes to the public health burden worldwide, although its incidence rates have long been declining in various parts of the world[1,2]. Gastrectomy remains the most important curative treatment for GC. However, recovery after surgery can vary, particularly among elderly patients and/or individuals with limited baseline physiological reserves. However, total gastrectomy is associated with a particularly high incidence of postoperative complications and mortality, as well as considerable nutritional compromise and non-insignificant readmission rates, emphasizing the need for efficient perioperative care and surveillance of recovery[3,4].

The preoperative comorbidity profile is a major source of differentiation during short-term recovery after major oncological abdominal surgeries. Comorbidities are prevalent among patients with GC and affect perioperative stress responses, nutritional status, and postoperative complication risks. Classical studies have established the prognostic importance of measuring the severity of comorbidities[5], and subsequent refinements support its application in modern risk adjustment[6]. Among GC surgery cohorts, comorbidities have consistently been associated with postoperative complications and heterogeneity in recovery, including laparoscopy-assisted gastrectomy and total gastrectomy[7,8]. Related perioperative risk stratification tools, such as the American Society of Anesthesiologists (ASA) physical status classification, have also demonstrated associations with short- and long-term outcomes of GC surgery and other major gastrointestinal procedures[9-11].

In addition to comorbidity severity, perioperative nursing processes are actionable mediators that can influence recovery trajectories. Several nursing-relevant process indicators, including time to first ambulation, time to first oral intake, and timing of nasogastric tube removal, are frequently used as pragmatic measures of postoperative functional recovery and care pathway performance. Reports have shown that early postoperative mobilization after gastrointestinal surgery is associated with favorable recovery profiles, although the effects can vary depending on procedure type and protocol adherence[12]. Similarly, early oral feeding after gastrectomy has been evaluated in clinical studies and meta-analyses, supporting its feasibility and potential benefits without clear signs of increased complications in appropriately selected patients[13-15]. Routine postoperative decompression with nasogastric tubes has also been questioned, and meta-analytical evidence regarding gastrectomy shows that routine nasogastric or nasojejunal decompression may be unnecessary in several cases[16,17]. Importantly, the real-world effectiveness of these process indicators may depend on baseline patient complexities, including comorbidity severity and nutritional reserve.

Nutritional status is particularly important during GC surgery. Preoperative and early postoperative malnutrition markers, such as albumin, anemia, and low body mass index, are commonly monitored and associated with adverse postoperative outcomes across surgical oncology contexts and in GC-specific analyses[4,18,19]. Given that comorbidity severity can occur simultaneously with nutritional impairment, evaluating comorbidity strata, along with nursing process indicators, may offer a more clinically interpretable picture of recovery variability after total gastrectomy.

Enhanced recovery frameworks provide evidence-based structures for perioperative optimization in gastrectomies, emphasizing multimodal perioperative management and measurable milestones in recovery[20]. Several studies and evidence syntheses in GC gastrectomy populations have reported that structured perioperative pathways can shorten hospital stay and accelerate functional recovery, although these effects may be influenced by patient selection and baseline risk profiles such as comorbidity severity[21-23]. However, practically, even with increasing evidence regarding protocolized perioperative care, data-driven correlational studies that investigate the associations among the severity of preoperative comorbidities, perioperative nursing process indicators, and postoperative recovery outcomes in a single defined surgical group, such as patients with GC undergoing total gastrectomy, are scarce.

Accordingly, we examined the relationship among the severity of preoperative comorbidities, perioperative nursing process indicators, and postoperative recovery in patients who underwent total gastrectomy for GC, including times to first ambulation, first oral intake, and removal of the nasogastric tube. By quantifying recovery using clinically meaningful outcomes, including postoperative recovery time, length of hospital stays, and delayed recovery thresholds, we sought to clarify whether comorbidity severity is associated with prolonged recovery and whether nursing process indicators exhibit measurable relationships with recovery endpoints in this patient population.

MATERIALS AND METHODS

Study design and setting

This retrospective cohort study was performed at the First Affiliated Hospital of Anhui Medical University, a tertiary center located in Anhui Province, China. The electronic medical record system of the hospital was used to identify patients who underwent total gastrectomy for histologically proven GC within the study period. The study protocol was approved by the Institutional Review Board of the First Affiliated Hospital of Anhui Medical University (Approval No. PJ2025-12-34) and was conducted in accordance with the Declaration of Helsinki. Informed consent for data use was obtained from all patients, and all data were anonymized before analysis.

Patient selection

The inclusion criteria were as follows: Patients were more than 18 years, had pathologically confirmed gastric adenocarcinoma, and had undergone total gastrectomy with curative intent. To ensure comparability across analyses, only patients with complete perioperative data, nursing process indicators, and hospitalization outcomes were included in the study. Patients who simultaneously underwent subtotal gastrectomy, palliative or emergency surgery, or other major procedures that may have a major impact on postoperative recovery were excluded. Furthermore, those with missing important variables, such as baseline characteristics, nursing process indicators, or recovery outcomes, were also excluded. Finally, patients who died within 48 hours postoperatively were excluded to avoid bias introduced by death in the immediate postoperative period, which would have precluded the assessment of recovery trajectories.

Sample size

The sample size was based on the number of consecutive eligible patients who underwent total gastrectomy for GC at the authors’ institution during the study period and who fulfilled the predetermined inclusion and exclusion criteria. Data from 174 patients were included in the final analysis. This sample size was adequate for investigating the potential relationships among the severity of preoperative comorbidities, perioperative nursing process measures, and postoperative recovery outcomes in multivariable regression models.

Data collection

Clinical data were extracted from electronic medical records by two independent investigators using a standardized data abstraction form. Data on age and sex were extracted as demographic characteristics. Other information included the following: Admission and discharge diagnoses, laboratory indicators used in the baseline assessment, such as hemoglobin and albumin levels, perioperative clinical information, nursing process indicators, and hospitalization outcomes. Any discrepancies between the two investigators were resolved by consensus after rechecking the source records.

Definition and grading of preoperative comorbidity severity

The severity of preoperative comorbidities was assessed based on the overall clinical impact of the study. Patients were classified into three groups depending on severity: No or mild comorbid conditions with negligible influence on perioperative management (severity grade 0), clinically significant comorbidities that needed to be actively managed perioperatively (severity grade 1), and severe or high-risk comorbidities such as multisystem disease or diseases that confer significantly elevated perioperative risk (severity grade 2). This severity-based categorization was established after a meticulous review of admission and secondary discharge diagnoses and was designed to serve as a surrogate indicator of escalating physiological vulnerability.

Perioperative nursing care and process indicators

Standardized and professionally supervised clinical protocols were applied to the perioperative care of all patients during the study. These protocols included full preoperative preparation and defined postoperative management aligned with the quality and consistency of nursing care throughout the study population. Preoperative assessment, nutritional support and counseling, respiratory training, psychological support, early postoperative mobilization, and standardized protocols for functional recovery are the main components of perioperative nursing care. Within this routine care, nursing care was individualized depending on the clinical condition of each patient at baseline. For patients with a greater preoperative comorbidity burden, nursing care focused more on a thorough cardiopulmonary evaluation, enhanced perioperative surveillance, tailored nutritional support, and guided mobilization. After surgery, oral feeding was reintroduced and the nasogastric tube was removed progressively depending on the gastrointestinal tolerance of the patient following institution-defined protocols for ward care, supported by day-to-day input from a team of specialty professionals.

All nursing procedures were performed by a professional nursing team that adhered to the protocol, and patients were not removed from professional perioperative nursing care. This uniform but risk-adapted nursing strategy was established to achieve safe and successful functional recovery in patients with diverse baseline health and prevent potential delays in postoperative recovery due to a high comorbidity burden.

Outcome measures

Postoperative recovery outcomes were assessed based on the postoperative recovery period and length of hospital stay. Postoperative recovery time was defined as the number of days required to fulfill specified clinical criteria for recovery recorded in the medical records. The length of hospital stay was defined as the interval between admission and hospital discharge. Delayed recovery was defined as a postoperative recovery ≥ 8 days. This threshold was chosen based on the distribution of postoperative recovery duration in the study population, corresponding to the approximate upper half of the observed recovery durations, and served to enable clinically meaningful stratified analyses.

Available nursing process indicators were dichotomized for secondary analyses using clinically meaningful time cutoffs as follows: Early ambulation within two postoperative days, early oral intake within three postoperative days, and nasogastric tube removal within four postoperative days. These cutoffs are representative of important early recovery events that are typically used in perioperative nursing care after gastrectomy.

Although validated indices such as the Charlson comorbidity index are widely used for comorbidity assessment, this study adopted a pragmatic severity-based categorization to reflect the overall perioperative management burden documented in the medical records.

Statistical analysis

Statistical analyses were performed using SPSS version 29.0 (IBM Corp., Armonk, NY, United States). Continuous variables were evaluated for normality and expressed as mean ± SD, and categorical variables are expressed as n (%). To examine the differences between the severity of comorbidity groups, one-way analysis of variance was used for continuous variables, and the χ² test or Fisher’s exact test was used for categorical variables. Multivariable logistic regression analysis was performed to determine predictors of prolonged recovery (≥ 8 days), with results expressed as adjusted ORs with a corresponding 95%CI. The relationship between the severity of comorbidities and ASA physical status was analyzed using the χ² test and linear-by-linear association test. All statistical tests were two-sided, and differences with P ≤ 0.05 were considered to be significant.

RESULTS

Baseline characteristics depending on comorbidity severity

After rigorous review, 174 patients diagnosed with GC who underwent total gastrectomy were included in the analysis. The patients were categorized into 3 groups depending on the severity of their preoperative comorbidities (grades 0, 1, and 2). Baseline demographic and clinical features are presented in Table 1.

Table 1 Baseline characteristics of patients stratified by comorbidity severity, mean ± SD.

Variable	Comorbidity 0	Comorbidity 1	Comorbidity 2	P value
Age (year)	66.94 ± 9.51	68.54 ± 8.45	62.77 ± 11.87	0.172
Male sex, n (%)	104 (83.9)	30 (81.1)	10 (76.9)	0.785
BMI (kg/m2)	21.01 ± 1.08	20.59 ± 1.22	19.77 ± 1.43	< 0.001
Hemoglobin (g/dL)	13.38 ± 0.89	13.07 ± 0.86	12.60 ± 1.29	0.006
Albumin (g/L)	37.22 ± 1.86	34.34 ± 1.96	34.98 ± 1.57	< 0.001
ASA physical status				< 0.001
ASA I	24	1	0
ASA II	75	22	4
ASA III & IV	25	14	9

BMI: Body mass index; ASA: American Society of Anesthesiologists.

No statistically significant differences in age or sex distribution were observed among the three groups (P > 0.05). However, baseline nutritional status was quite different among the various comorbidity severity strata. Patients with more severe comorbidities exhibited significantly lower body mass index, hemoglobin, and albumin levels (P < 0.01). Moreover, a significant difference was found in the distribution of ASA physical status among the severity groups, with the proportion of patients with ASA III-IV status being significantly greater among those with higher comorbidity severity (P < 0.001).

Perioperative nursing process indicators depending on comorbidity severity

Preoperative nursing process indicators depending on comorbidity severity are presented in Table 2. Preoperative wait times were not significantly different among the 3 groups (P = 0.266). In contrast, significant differences in comorbidity severity were observed at several milestones in nursing care following surgery. The time to first ambulation differed significantly and increased with higher severity grades (P < 0.001). Similarly, those with higher comorbidities experienced a delayed time to first oral intake and later removal of the nasogastric tube (P < 0.001).

Table 2 Perioperative nursing process indicators according to comorbidity severity, mean ± SD.

Indicator (day)	Comorbidity 0	Comorbidity 1	Comorbidity 2	P value
Preoperative waiting time	3.65 ± 2.04	3.35 ± 1.92	4.46 ± 3.13	0.266
Time to first ambulation	2.50 ± 0.28	2.74 ± 0.20	3.48 ± 0.12	< 0.001
Time to first oral intake	3.30 ± 0.28	3.54 ± 0.20	4.38 ± 0.12	< 0.001
Time to NG tube removal	4.00 ± 0.28	4.24 ± 0.20	5.28 ± 0.12	< 0.001

NG: Nasogastric.

Postoperative recovery outcomes depending on comorbidity severity

Postoperative recovery results are presented in Table 3. The mean times for postoperative recovery and hospital stay are not significantly different among the different comorbidity severity groups (P > 0.05). With delayed postoperative recovery defined as > 8 days, the three comorbidity severity groups exhibited no significant differences in the rate of delayed recovery (P = 0.321).

Table 3 Postoperative recovery outcomes by comorbidity severity, mean ± SD.

Outcome	Comorbidity 0	Comorbidity 1	Comorbidity 2	P value
Postoperative recovery time (day)	8.25 ± 2.13	8.00 ± 2.01	8.62 ± 2.14	0.643
Length of hospital stay (day)	11.90 ± 2.78	11.35 ± 2.51	13.08 ± 3.48	0.157
Delayed recovery (≥ 8 days), n (%)	69 (55.6)	17 (45.9)	9 (69.2)	0.321

Association between individual nursing process indicators and delayed recovery

Data on the relationship between perioperative nursing process indicators and delayed recovery are presented in Table 4. No significant difference in delayed recovery was observed between patients who ambulated within two postoperative days and those who ambulated subsequently. Delayed recovery was significantly less frequent among patients who resumed oral intake within 3 postoperative days than among those who resumed oral intake subsequently. No significant association was observed between delayed recovery and nasogastric tube removal within four postoperative days vs subsequent removal.

Table 4 Association between nursing process indicators and postoperative recovery, n/total (%).

Nursing indicator	Category	Delayed recovery ≥ 8 days	P value
Time to first ambulation (day)	≤ 2	3/6 (50.0)	1.000
	> 2	92/168 (54.8)
Time to first oral intake (day)	≤ 3	6/23 (26.1)	0.006
	> 3	89/151 (58.9)
NG tube removal time (day)	≤ 4	34/72 (47.2)	0.137
	> 4	61/102 (59.8)

NG: Nasogastric.

Multivariable analysis of factors associated with delayed recovery

Multivariate logistic regression analysis was performed to identify predictors of delayed recovery (i.e., ≥ 8 days), and the results are presented in Table 5. After adjusting for potential confounders, the severity of comorbidities did not exhibit a positive independent association with delayed recovery [adjusted OR = 0.313 (95%CI: 0.135-0.722); P = 0.006]. Time to first oral intake was an important predictor of late recovery [adjusted OR = 17.179 (95%CI: 3.540-83.373); P < 0.001]. In the adjusted model, age and sex were not independently associated with delayed recovery.

Table 5 Multivariable logistic regression analysis for delayed recovery (≥ 8 days).

Variable	Adjusted OR	95%CI	P value
Age (per year)	0.961	0.922-1.002	0.06
Male sex	2.34	0.958-5.716	0.062
Comorbidity severity	0.313	0.135-0.722	0.006
Time to first oral intake (day)	17.179	3.540-83.373	< 0.001

Association between comorbidity severity and ASA physical status

The associations between comorbidity severity and ASA physical status are presented in Table 6. A significant positive association was observed between worsening comorbidity severity and higher ASA physical status (P < 0.001). Patients with higher comorbidity severity were also more likely to have an ASA III-IV status, indicating an increased perioperative risk.

Table 6 Correlation between comorbidity severity and American Society of Anesthesiologists physical status.

Comorbidity severity	ASA I	ASA II	ASA III-IV	P value
0	24	75	25	< 0.001
1	1	22	14
2	0	4	9

ASA: American Society of Anesthesiologists.

DISCUSSION

This study investigated the relationship among preoperative comorbidity severity, perioperative nursing process indicators, and postoperative recovery in patients who underwent total gastrectomy for GC. Several noteworthy results have been previously reported. Patients with more severe comorbidities had worse baseline nutritional status and higher ASA physical status scores, implying higher physiological vulnerability before surgery. Second, more severe comorbidities were significantly associated with delays, such as delayed ambulation and oral intake and prolonged use of a nasogastric tube, in some nursing milestones in the perioperative period. However, after adjusting for these differences, the severity of comorbidities did not exhibit a positive independent association with delayed recovery. In contrast, time to first oral intake was identified as a significant independent predictor of prolonged recovery.

Severe preoperative conditions have been reported as crucial factors for operative risk in patients with GC. Increased comorbidity severity correlates with increased postoperative morbidity and extended hospital stay after gastrectomy. For example, earlier reports addressing recovery after gastrectomy have noted that patients with multiple preoperative health problems typically experienced a slower return of bowel motility and extended hospitalization than those who were more robust, even in curable gastrectomy settings[24]. Jeong et al[25] observed that multiple factors contribute to surgical outcomes and that baseline health status and perioperative care procedures may have diverse effects on functional recovery processes after gastrectomy.

In this study, sicker patients had a lower body mass index, hemoglobin, and albumin levels, as well as a higher ASA physical status class, indicating a higher overall physiological risk and worse nutritional reserves. These results are consistent with the literature reporting that poor preoperative nutritional status correlates with negative surgical outcomes and delayed postoperative functional recovery, particularly for major gastrointestinal surgeries in which metabolic or functional demands are high. Poor nutritional status at baseline has been associated with increased postoperative morbidity and slower functional recovery after major cancer resection in several cohorts.

Nevertheless, comorbidity severity was not found to be an independent risk factor for late postoperative recuperation after adjustment. This implies that baseline morbidity severity may have less of an effect on early recovery under perioperative management. Recent studies have supported that tailored perioperative treatment can affect functional recovery, even in patients with numerous comorbidities.

The perioperative nursing indicator most strongly associated with postoperative recovery was early initiation of oral intake. Early oral feeding after gastrectomy has been extensively investigated and is associated with better postoperative outcomes such as earlier bowel function and shorter length of hospital stay without excess complications[15,24]. These results were corroborated by a randomized clinical trial that reported that early oral feeding after gastrectomy is safe, does not increase major postoperative complications, and promotes recovery in clinically relevant terms[26]. A recent meta-analysis by Mohajeri et al[27] further showed that early oral feeding after gastrectomy shortens hospital stay, accelerates bowel function recovery, and does not increase postoperative complications, which is consistent with our findings. Similar benefits have also been reported in meta-analyses of early enteral or oral feeding in gastrointestinal surgery[28].

In our univariate analyses, early ambulation and nasogastric tube removal, which are nursing process indicators, were not significantly associated with delayed recovery. This observation is consistent with that of other studies, indicating that a single intervention does not dictate recovery; rather, the sum of a multitude of perioperative care processes in a coordinated approach has the greatest effect on functional outcomes. Our multivariable prediction model demonstrated superior performance with the inclusion of nursing process indicators, indicating that integrated nursing care has a significant effect on recovery over and above baseline patient demographics.

Importantly, this study shows that comorbidity severity is inversely associated with delayed recovery after adjustment. Therefore, these findings should be interpreted cautiously. A possible explanation is that patients with more severe comorbidities may have received more intensive or customized perioperative nursing care, which could attenuate the detrimental impact of baseline risk factors. In addition, because postoperative oral intake timing was included in the adjusted model, the observed inverse association may reflect model dependency, mediation by postoperative care process variables, or residual confounding rather than a true protective effect of a greater comorbidity burden.

The definition of delayed recovery in this study was relatively broad and requires further discussion. As no well-established cut-off defining delayed functional recovery following total gastrectomy has been reported, we used a data-driven threshold by considering the distribution of postoperative recovery time in our cohort. A recovery period of ≥ 8 days was chosen to define a fairly long recovery period because it approximated the higher end of recovery times and enabled a simple two-way division of patients with an unusually long recovery period after surgery. This method has frequently been used in retrospective surgical reviews for high interpretability without losing information through arbitrary dichotomization. However, the results for other cut-offs may differ, and further research with a larger sample size or prospective design may assist in defining standardized criteria for delayed recovery after gastrectomy.

Studies have achieved analogous reports in which the start time of oral intake and achievement of functional recovery milestones were evaluated at predetermined postoperative time points. As an illustration, early oral feeding is safe and feasible and is associated with a reduction in the length of hospital stay and earlier return of bowel function in patients who have undergone gastrectomy for GC[14,29]. A systematic review confirmed the safety and benefits of recovery from early feeding over delayed feeding[15]. These studies have demonstrated that recovery milestones at specific postoperative time points can be of clinical relevance; however, the exact thresholds may differ in different settings and subject populations.

The strong association between comorbidity severity and ASA physical status further validates the significance of comorbidity stratification. Because the ASA physical status classification is a well-established surrogate for preoperative physical status and anesthetic risk and is highly correlated with our comorbidity grading system, the system reflects clinically important variations in patient health status.

Interestingly, the severity of comorbidity was not significantly associated with the mean duration of postoperative recovery but was associated with delayed recovery when the length of recovery was oriented with a dichotomous cut-off. This distinction reflects different clinical perspectives and is not contradictory. Time to recovery refers to the overall recovery at the cohort level, whereas delayed recovery captures a subset of patients recovering in a clinically meaningful manner. From a clinical perspective, a dichotomized analysis is particularly important because it enables the identification of patients who potentially require more observation and intense nursing care. Within this framework, it appears that greater comorbidity severity may predispose patients to delayed recovery. However, in the context of standardized and professionally delivered perioperative nursing care, this higher risk could be counterbalanced to result in a major prolongation of recovery time in terms of population means.

This study had some limitations. First, its retrospective design may have led to selection bias and residual confounding factors. Second, although our grading of comorbidity severity was clinically meaningful, it did not address all the elements of functional status or frailty that could influence recovery after surgery. Third, the present study was designed to evaluate early postoperative recovery; we did not evaluate long-term functional outcomes or quality of life, which would have been informative as complementary findings. Finally, the single-center design may limit the generalizability of the results; therefore, additional multicenter studies are recommended. In addition, comorbidity severity was graded using a study-specific clinical categorization rather than a validated index such as the Charlson comorbidity index, which may limit reproducibility and comparability across studies.

CONCLUSION

Patients with severe preoperative comorbidities who underwent total gastrectomy for GC exhibited worse baseline nutritional status and delayed perioperative nursing milestones; however, this was not an independent predictive factor for delayed postoperative recovery after adjustment. Early oral intake was independently associated with early recovery, emphasizing the role of perioperative nursing care as a modifiable factor. These results provide a basis for integrating structured patient-centric nursing interventions that focus on facilitating early functional milestones to enhance postoperative recovery in patients undergoing high-risk surgeries.