Effect of early stepwise nutrition management on feeding tolerance of postoperative patients with gastric cancer

Abstract

BACKGROUND

Postoperative nutritional management of gastric cancer (GC) remains a problem that needs to be solved in clinical treatment.

AIM

To develop an early graded nutrition management plan and evaluate its impact on feeding tolerance, nutritional status, and prognosis.

METHODS

In total, 142 patients who underwent laparoscopic radical gastrectomy at Jiujiang University Affiliated Hospital between August 2021 and August 2022 were included in this study. Based on postoperative nutritional management and feeding, the patients were divided into observation and control groups. The general information questionnaire, Visual Analog Scale, and Pittsburgh Sleep Quality Index were used to evaluate pain and sleep of patients, respectively. Independent sample t-test and χ² test were used to analyze differences between groups.

RESULTS

The feeding intolerance rates in the control and observation groups were 13.2% and 4.1%, respectively. Hospitalization time and first defecation times in the observation group were shorter than those in the control group. Hemoglobin, prealbumin, transferrin, and immunological indices in the observation group were significantly higher than those in the control group 7 days after surgery, whereas calcitonin levels were significantly lower than those in the control group (P < 0.05). In general, the nutritional status of the observation group was better than that of the control group, and pain and sleep quality scores improved.

CONCLUSION

Compared with the conventional postoperative feeding, early stepwise nutritional management can significantly enhance the nutritional status of patients with GC after surgery, improve their feeding tolerance, and reduce postoperative complications.

Key Words: Gastric cancer; Parenteral nutrition; Oral enteral nutrition; Early stepwise nutrition, Postoperative prognosis

Core Tip: Early stepwise nutrition management benefits postoperative gastric cancer patients. It reduces feeding intolerance, shortens hospitalization and first defecation time, improves nutritional and immunological status, and enhances pain and sleep quality, with no significant impact on overall survival.

INTRODUCTION

Worldwide, gastric cancer (GC) constitutes a leading cause of cancer-associated mortality[1]. Approximately 65%-85% of patients with GC experience malnutrition[2,3]. Given the distinct pathophysiology of this malignancy, malnutrition has emerged as a critical determinant influencing clinical outcomes, including overall and disease-specific survival[4]. Common manifestations of nutritional deficits include hypoalbuminemia, organ dysfunction, and immunosuppression. Furthermore, malnutrition is linked to an increased risk of postoperative complications such as surgical site infections, dumping syndrome, and pancreatic exocrine insufficiency. Malnutrition and related complications account for 40% of cancer deaths[5]. Therefore, early nutritional screening, timely intervention, and correction of dietary deficiencies are essential to improving postoperative recovery and long-term prognosis in GC patients.

Postoperative nutritional support maintains the nutritional status of the body during the postoperative catabolic period, which is the main determinant of recovery after abdominal surgery[6]. Nutritional support currently includes enteral and parenteral nutrition. Parenteral nutritional support can alleviate malnutrition to a certain extent and is the first choice for patients who cannot receive oral nutrition. However, this can lead to atrophy of the gastric mucosa because of the stimulation of the gastrointestinal tract by a long-term lack of food. It also slows the recovery of the intestinal barrier, leading to an imbalance in the normal intestinal flora and a reduction in its ability to absorb nutrients. The study by Jiang et al[7] found that preoperative short-term parenteral support may not have significant benefits for complications or overall survival among GC patients. For patients with GC, intestinal function recovered within 6-12 hour after surgery, suggesting that early oral enteral nutrition (EN) support after surgery is feasible and safe[8]. The Enhanced Recovery After Surgery guidelines recommend starting postoperative oral nutrition on the first day after gastric surgery[9]. Moreover, early EN can stimulate the recovery of normal peristalsis of the gastrointestinal tract, accelerate the recovery of absorption, and avoid excessive infusion volume that aggravates the burden of the gastrointestinal tract[10]. This positively affects the recovery of patients with GC. Chen et al[11] found that EN was safe and well tolerated, shortened the length of hospital stay, and reduced the cost of total gastrectomy for GC. A case-control study by Jang and Jeong[12] also confirmed these findings. However, for GC patients, postoperative nutritional recovery is often a long and complex process. Especially for some patients who cannot tolerate EN, how to accurately calculate their nutritional requirements in the early postoperative stage and develop a safe, effective, and individualized nutritional support plan are still key issues that need to be further explored in current clinical practice. Therefore, the establishment of early scientific and reasonable nutritional support and management system may significantly promote the overall postoperative rehabilitation of GC patients, further reduce the risk of complications, and effectively reduce feeding intolerance. In this context, by constructing a systematic early stepwise nutrition management (ESNM) program after GC surgery, this study aims to compare the differences in feeding tolerance of patients under different nutritional intervention models, and to analyze its related influencing factors and internal mechanisms. Through empirical data, this study hopes to provide a basis for reducing postoperative complications, improving nutritional status and clinical prognosis of patients, and also provide valuable theoretical reference and practical insights for the formulation of scientific and reasonable nutritional management strategies for patients with GC after surgery.

MATERIALS AND METHODS

Research participants

This study was approved by Jiujiang University Affiliated Hospital and was conducted in accordance with the Declaration of Helsinki (revised in 2013). This study was a randomized controlled trial, with two-sided testing, α = 0.05, and a 1:1 sample size ratio for the four groups. According to a previous study by the group and relevant literature, the feeding intolerance rates of the two groups were 15% and 5%, respectively. PASS 15 software was used to calculate the sample size of the two groups (each n = 45 cases). In total, 142 patients who underwent laparoscopic radical gastrectomy at Jiujiang University Affiliated Hospital from August 2021 to August 2022 were included. Patients were categorized into two groups according to postoperative nutritional management and feeding protocols: (1) An observation group (n = 74); and (2) A control group (n = 68) (Figure 1).

Figure 1 Summary of graphics. BMI: Body mass index; Hb: Hemoglobin; IgA: Immunoglobulin A; IgG: Immunoglobulin G; IgM: Immunoglobulin M; PAB: Prealbumin; PSQI: Pittsburgh Sleep Quality Index; VAS: Visual Analog Scale.

Inclusion criteria: (1) Age ≥ 18 years; (2) All patients meeting the relevant diagnostic criteria of GC from "Chinese Consensus on Screening, Endoscopic Diagnosis and Treatment of Early Gastric Cancer”, and diagnosed by pathological examination; and (3) Receiving laparoscopic radical gastrectomy, informed consent was obtained.

Exclusion criteria: (1) Serious concomitant diseases, including chronic cardiopulmonary disease and chronic renal failure; (2) Pregnant or breastfeeding women; (3) Nutritional Risk Screening 2002 score of less than 3; (4) Diagnosis of immune disorders or known immunodeficiency; and (5) Unconsciousness, inability to communicate, or cognitive impairment.

Collection of demographic and general clinical indicators

The demographic indicators included demographic data (such as age, duration of disease, weight, course of disease, hypertension, diabetes) and clinical data – serological indicators such as hemoglobin (Hb), serum total protein (STP), albumin (Alb), prealbumin (PAB), transferrin (TRF), C-reactive protein (CRP), procalcitonin (PCT); immune indicators such as immunoglobulin A (IgA), immunoglobulin M (IgM), immunoglobulin G (IgG); triceps skinfold thickness, body mass index (BMI), upper arm muscle circumference; clinical symptoms included nausea and vomiting, aspiration, diarrhea, gastric retention, abdominal pain, abdominal distension, infection, recovery time of bowel sounds, first exhaust time, and first defecation time.

Intervention plan

When patients of either group were admitted to the hospital, the nursing staff popularized the knowledge of GC-related diseases, possible causes, and triggers for the patients and their families and informed them of the precautions and purposes of preoperative and postoperative abstinence and fasting, as well as gastrointestinal decompression, to improve treatment compliance. Basic treatments such as fasting, gastrointestinal decompression, and anti-inflammatory fluid replacement were administered according to the doctors’ advice. For patients with other underlying diseases, appropriate treatments were provided. For instance, patients with hypertension received antihypertensive treatment, whereas those with hyperglycemia received treatment for hypoglycemia. During the treatment process, changes in the patient’s vital signs, such as blood pressure, were monitored, and psychological guidance was provided. When discharged from the hospital, patients were provided guidance to avoid triggering factors and were advised to lead a regular life, perform appropriate exercise, avoid fatigue, and undergo regular checkups. All included patients were followed up for 3 years, and the 3-year survival rate was calculated.

Control group

Parenteral nutritional support was provided 24 hours after operation to establish peripheral venous access or central venous access (including through the subclavian deep vein and internal jugular deep vein). Based on the patient's basic condition (disease condition, BMI, physiological needs, etc.), the energy required by the patient was calculated, and water, protein, carbohydrates, and trace elements were replenished in a timely and sufficient manner. Intravenous infusion of 10% fat emulsion (500 mL), 7% amino acids (750 mL), and 25% glucose (1000 mL) was routinely administered. Blood glucose management was performed throughout the perioperative period, maintaining glycated Hb < 8.5%, pre-meal blood glucose of 8-10 mmol/L, and random blood glucose of 8-12 mmol/L 2 hours after a meal or when unable to eat. The energy intake was approximately 25-30 kcal/kg/day, the calorie intake was calculated at 104.65-125.58 kJ/kg/day, and the target protein requirement was recommended to be calculated at 1.2-1.5 g/kg/day. Continuous infusion was administered until the patient could eat normally. During parenteral nutrition, the nutrient solution was prepared strictly according to the dosage. Therefore, the principles of immediate preparation, use, and sterility were strictly followed. When infusing, attention was paid to the infusion speed, time, and temperature to reduce patient discomfort.

Observation group

An early stepwise nutritional management intervention was administered based on the control group. From the first postoperative day, approximately 500-1000 mL of liquid or oral nutritional preparations were consumed. Therefore, oral nutrition preparations were recommended. Patients undergoing non-total gastrectomy transitioned to solid food on the second and third days and adjusted their food intake according to tolerance of the gastrointestinal tract. EN was recommended for patients with preoperative malnutrition, nutritional risk, expected inability to eat for more than 5 days after surgery, or expected oral intake of less than 50% for more than 7 days after surgery. EN was recommended to start at a low rate (10-20 mL/hour) and a low dose, and the dosage was gradually increased according to the patient's tolerance. Generally, it takes 5-7 days to adjust the target intake. If the energy and protein intake of EN was less than 50% of the target amount for more than 7 days, then parenteral nutrition was also initiated. Parenteral nutrition was administered as early as possible in patients who could not tolerate EN. Parenteral nutrition was recommended through a central venous approach, with an integrated three-chamber bag as the first choice. Postoperative intestinal obstruction, severe anastomotic fistula, gastrointestinal bleeding, intestinal ischemic disease, and septic shock are contraindications for oral or EN. Usually, parenteral nutrition is administered first, and the transition to EN is gradually attempted after symptoms are controlled. Nutrient infusion, speed, and other factors were the same as those in the control group. Throughout the process of using the nutritional infusion pump, the patient was closely monitored for symptoms of feeding intolerance, such as vomiting, abdominal pain, diarrhea, and abdominal distension. If such symptoms were noted, the patients were promptly treated. Serological indicators, such as electrolytes and blood routine, were regularly tested and the total amount and concentration of the nutrient solution were adjusted based on the test results. Both groups were administered the oral interventions until the patients began oral intake.

Evaluation criteria for feeding intolerance: If the residual gastric amount extracted every 6 hours after infusion of the nutrient solution exceeded 200 mL. Alternatively, feeding intolerance was also considered if a minimum feeding amount of 20 kcal/kg (1 kcal = 4.18 kJ) per day was not achieved within 72 hours after the infusion of nutrition.

Visual analog scale and Pittsburgh Sleep Quality Index scales

At 1 day, 3 days, 5 days, and 7 days after the operation, the Visual Analog Scale (VAS)[13] was used to evaluate pain. The total score is 10 points, and a higher score indicates pain of greater severity. At the same postoperative days, the Pittsburgh Sleep Quality Index (PSQI)[14] was used to evaluate sleep quality. The total score is 21 points, and a higher score indicates worse sleep quality.

Statistical analysis

Statistical analyses were conducted with Statistical Package for the Social Sciences 26.0 (IBM Corp., Armonk, NY, United States). Continuous data are presented as mean ± SD, while categorical variables are summarized as frequencies and percentages. Group comparisons were carried out using t-test for continuous variables and the χ² test for categorical data. Survival analysis was performed using the Kaplan-Meier method, and differences between groups were assessed with the log-rank test.

RESULTS

Baseline data

No significant differences were observed in age, sex, disease course, body weight, hypertension, or diabetes between the two groups (P > 0.05), indicating that the two groups were balanced and comparable (Table 1).

Table 1 Baseline data, mean ± SD.

Item	Control group	Observation group	t/χ²	P value
Age (years)	54.12 ± 7.89	54.42 ± 7.13	-0.226	0.842
Sex			0.048	0.872
Male	38	40
Female	30	34
Duration (months)	2.12 ± 0.31	2.06 ± 0.37	0.231	0.819
Body weight (kg)	57.56 ± 18.74	58.98 ± 20.65	0.384	0.904
Hypertension			0.183	0.669
Yes	27	32
No	41	42
Diabetes			0.123	0.726
Yes	22	26
No	46	48

Recovery of gastrointestinal function

Overall, patients in the observation group demonstrated accelerated recovery compared to the control group, as evidenced by shorter durations in hospital stay, earlier return of bowel sounds, and reduced time to first exhaust and first defecation. However, among these parameters, only the length of hospital stays (12.63 ± 3.79 days vs 14.89 ± 4.13 days, P < 0.05) and the time to first defecation (68.02 ± 7.40 hours vs 71.64 ± 8.51 hours, P < 0.05) reached statistical significance. The detailed results are presented in Table 2.

Table 2 Comparison of the recovery of gastrointestinal function between the two patient groups, mean ± SD.

Item	Length of hospital stay (days)	Bowel sound recovery time (hours)	First defecation time (hours)	Time of first defecation (hours)
Control group	14.89 ± 4.13	37.95 ± 3.64	61.12 ± 6.78	71.64 ± 8.51
Observation group	12.63 ± 3.79	37.23 ± 3.76	60.85 ± 7.01	68.02 ± 7.40
t value	5.892	0.141	0.293	4.713
P value	0.000	0.972	0.766	0.000

Postoperative serological and immunological indicators

No significant differences were noted in Hb, Alb, STP, PAB, TRF, CRP, and PCT levels and IgA, IgG, and IgM levels between the observation and control groups 1 day before the operation (P > 0.05). At 7 days after operation, there were significant differences in Hb, PAB, TRF, PCT, IgA, IgG, and IgM levels between the two groups (P < 0.05). At day 7, Hb, PAB, TRF, IgA, IgG, and IgM levels in the observation group were significantly higher, and PCT levels were significantly lower (P = 0.035) (Tables 3 and 4).

Table 3 Comparison of postoperative serological indicators between the two patient groups, mean ± SD.

Item	Hemoglobin (g/L)	Albumin (g/L)	Serum total protein (g/L)	Prealbumin (mg/L)	Transferrin (g/L)	C-reactive protein (mg/L)	Procalcitonin (ng/L)
1 day before the operation
Control group	108.25 ± 8.12	35.68 ± 2.65	48.65 ± 6.01	216.45 ± 28.37	2.17 ± 0.75	8.17 ± 1.63	1.04 ± 0.43
Observation group	107.43 ± 5.67	34.71 ± 1.98	49.21 ± 5.54	220.12 ± 30.75	2.20 ± 0.68	8.43 ± 1.46	0.98 ± 0.34
t value	0.243	0.226	-0.188	-0.328	-0.215	-0.432	0.285
P value	0.804	0.823	0.815	0.742	0.784	0.731	0.784
7 days after the operation
Control group	110.32 ± 5.43	38.87 ± 2.98	56.68 ± 5.87	264.58 ± 25.61	2.20 ± 0.63	6.34 ± 1.27	0.76 ± 0.33
Observation group	117.68 ± 6.07	39.45 ± 3.41	58.75 ± 6.35	300.47 ± 38.38	2.76 ± 0.88	5.96 ± 1.45	0.42 ± 0.25
t value	-2.475	-1.052	-0.977	-2.786	-2.584	1.003	2.645
P value	0.025	0.284	0.324	0.010	0.032	0.312	0.035

Table 4 Comparison of immunological indexes of the two groups (g/L), mean ± SD.

Item	Immunoglobulin A		Immunoglobulin G		Immunoglobulin M
	1 day before operation	7 days after operation	1 day before operation	7 days after operation	1 day before operation	7 days after operation
Control group	2.03 ± 0.41	1.51 ± 0.37	5.53 ± 0.87	4.29 ± 0.73	0.81 ± 0.10	0.54 ± 0.07
Observation group	1.98 ± 0.39	1.82 ± 0.31	5.56 ± 0.79	5.09 ± 0.66	0.79 ± 0.08	0.62 ± 0.05
t value	0.193	-6.125	-0.087	-5.287	0.273	-2.986
P value	0.862	0.000	0.981	0.000	0.741	0.011

Comparison of nutritional status

No statistically significant differences were observed in baseline anthropometric parameters – including BMI, upper arm muscle circumference, and triceps skinfold thickness – between the two groups on the day preceding surgery (all P > 0.05). However, at postoperative day 7, significant intergroup differences emerged. The observation group exhibited markedly higher BMI values (19.43 ± 2.76 kg/m²vs 18.96 ± 2.98 kg/m², P < 0.05) and greater triceps skinfold thickness measurements (0.94 ± 0.06 cm vs 0.87 ± 0.13 cm, P < 0.05) compared with the control group. These results are summarized in Table 5.

Table 5 Comparison of nutritional status of the two groups, mean ± SD.

Item	Body mass index (kg/m2)		Upper arm muscle circumference (cm)		Triceps skinfold thickness(cm)
	IgG	IgM	IgG	IgM	IgG	IgM
Control group	19.76 ± 3.18	18.96 ± 2.98	20.11 ± 4.09	20.03 ± 3.77	1.03 ± 0.11	0.87 ± 0.13
Observation group	19.81 ± 3.02	19.43 ± 2.76	20.01 ± 3.98	19.95 ± 3.84	1.01 ± 0.12	0.94 ± 0.06
t value	-0.317	-2.997	0.968	0.752	0.912	2.007
P value	0.809	0.008	0.253	0.421	0.287	0.041

IgG: Immunoglobulin G; IgM: Immunoglobulin M.

Incidence of feeding intolerance

Postoperative complications were systematically evaluated and compared between the two cohorts. The incidence of feeding intolerance was significantly higher in the control group, occurring in 9 patients (13.2%), compared with only 3 cases (4.1%) in the observation group. Documented manifestations of intolerance included nausea, vomiting, abdominal pain, distension, and diarrhea. The observed difference in the rate of feeding intolerance between the groups was statistically significant (P = 0.049), as detailed in Table 6.

Table 6 Comparison of the incidence of feeding intolerance between the two groups, n (%).

Item	Nausea and vomiting	Aspiration of aspiration	Diarrhea	Abdominal pain and distention	Gastric retention	Infection	Others	Total number of cases
Control group	2	1	2	2	0	1	1	9 (13.2)
Observation group	1	0	1	1	0	0	0	3 (4.1)
t value	0.433	1.096	0.433	0.433	-	1.096	1.096	3.861
P value	0.510	0.295	0.510	0.510	-	0.295	0.295	0.049

Others include intestinal obstruction, gastrointestinal bleeding, and anastomotic leakage.

VAS and PSQI scores

According to the VAS score results, no statistically significant difference was observed in the pain status between two groups on the first day after surgery (P > 0.05), whereas the VAS scores of the observation group on the third, fifth and seventh days after surgery were significantly lower than (P < 0.05) (Figure 2A). According to the PSQI score results, no statistically significant difference was noted in sleep status between two groups on the first day after surgery (P > 0.05), whereas the PSQI scores of the observation group on the third, fifth and seventh days after surgery were significantly lower (P < 0.05; Figure 2B).

Figure 2 Comparison between the two groups. A: Comparison of postoperative Visual Analog Scale scores between the two groups; B: Comparison of postoperative Pittsburgh Sleep Quality Index scores between the two groups; C: Comparison of postoperative survival rate between the two groups. PSQI: Pittsburgh Sleep Quality Index; VAS: Visual Analog Scale.

Three-year survival rate after operation

The survival analysis revealed no statistically significant difference in the three-year postoperative survival rate between two groups (P > 0.05; Figure 2C).

DISCUSSION

Globally, GC ranks as the fourth most common cause of mortality among cancer-related deaths[15]. The nutritional status prior to surgery plays a critical role in determining prognostic outcomes, including overall and disease-specific survival, in GC patients undergoing surgical intervention[4]. Malnutrition is also considered one of the most important factors leading to postoperative complications and poor prognosis in patients with GC after gastrectomy[16,17]. Wang et al[18] evaluated nutritional status in 101 GC patients (81 subtotal and 20 total gastrectomies) and identified that 52.5% were either malnourished or at nutritional risk. In a study by Lee et al[19] 21.4% of patients remained malnourished 1 year after surgery. In a study of 2322 hospitalized GC patients in China, Guo et al[20] applied the Patient-Generated Subjective Global Assessment tool and demonstrated that 80.4% presented with malnutrition, among whom 45.1% required urgent nutritional intervention. Nutritional support currently includes both enteral and parenteral nutrition[21]. Parenteral nutrition support can alleviate malnutrition to a certain extent; however, the long-term lack of food stimulation of the gastrointestinal tract leads to gastric mucosal atrophy, delays intestinal barrier recovery, causes an imbalance in normal intestinal flora, reduces their ability to absorb nutrients, and increases the vulnerability of the patient to abdominal pain, aspiration, and other feeding intolerance symptoms, resulting in slow recovery[22]. In contrast, numerous studies have supported the advantages of early EN intervention in improving nutritional status and enhancing immune function[23,24]. However, for certain specific pathological conditions or postoperative situations, premature or inappropriate initiation of EN may exacerbate intestinal ischemia or reperfusion injury and even increase the risk of anastomotic leakage. Therefore, the selection of nutritional support strategies should consider the differences among individual patients and their gastrointestinal tract tolerance. Possible underlying mechanisms include enhancement of intestinal barrier function and local immunity by EN via direct mucosal nutrition, increased release of secretory IgA, and maintenance of the stability of the microbiota. However, in cases of unstable hemodynamics or severe damage to intestinal function, forced EN may have adverse effects owing to increased metabolic load and oxidative stress. Therefore, ESNM can provide scientific and reasonable nutritional support in time after surgery or in the early stage of disease by combining EN and parenteral nutrition intervention strategies. In this mode, nutrients can provide patients with sufficient calories and essential macronutrients and micronutrients through staged and individually adjusted infusion, which can effectively meet the energy needs of the body under high stress. Furthermore, the nutrition management plan emphasizes the dynamic adjustment of nutrient solution concentration, infusion rate, and total intake according to the patient's actual disease status, gastrointestinal tolerance, and metabolic characteristics. This step-by-step intervention strategy not only helps to maintain the normal structure and function of tissues and cells, but also promotes protein synthesis and reduces inflammatory response, so as to support the recovery of body function more effectively. At the same time, gradually adaptive feeding methods can significantly reduce the risk of feeding intolerance such as abdominal distension, diarrhea and vomiting, further improve the effect of nutritional intake, and ultimately have a positive impact on the short-term recovery and long-term prognosis of patients.

In this study, the length of hospital stays and time to first defecation in the observation group were shorter, indicating that early stepwise nutritional management can shorten the remission time of clinical symptoms in patients after GC surgery and accelerate the recovery process. Barlow et al[23] also reported similar results. Hur et al[24] found that early EN after GC surgery could shorten the hospital stay and improve many parameters of the postoperative quality of life of patients. This may be because providing nutritional management to patients in the early postoperative period can enable them to obtain sufficient calories in the early stages of the disease, improve their hypermetabolic and hypercatabolic states, and shorten the natural course of the disease. In addition, adjusting the total infusion volume and speed based on the patient's gastrointestinal function can stimulate the gastrointestinal tract to resume normal peristalsis, accelerate the recovery of absorption function, prevent excessive infusion volume and burden on the gastrointestinal tract, simultaneously inhibit the secretion of gastric acid, accelerate the recovery of the gastrointestinal mucosal barrier protection system, maintain the integrity of the intestinal mucosa, and protect the growth of intestinal flora. It can effectively relieve abdominal distension, abdominal pain, and other conditions and promote recovery from disease.

In addition, when the body is in a state of stress, protein catabolism increases, resulting in decreased ALB levels. In this study, after the intervention, Hb and TFR levels in the observation group were higher, and the incidence of feeding intolerance in the observation group was lower. This indicates that early stepwise nutritional management in patients with GC who had undergone surgery can improve their nutritional status and reduce the occurrence of feeding intolerance. The possible reasons can be summarized as follows: (1) Timely scientific and reasonable nutritional support in the early stage of disease recovery can provide patients with sufficient energy reserves, essential amino acids and a variety of micronutrients required by the body, so as to effectively meet the nutritional needs of postoperative hypermetabolic state; and (2) This step-by-step nutritional intervention can help reduce the decomposition and consumption of protein in the body, maintain nitrogen balance, protect lean tissue, and thus maintain the normal metabolism level of the body and promote tissue repair and functional recovery. In addition, gradually adjusting the feeding rate and concentration can also help to adapt to the changes of gastrointestinal function after surgery and reduce the burden of gastrointestinal tract, thereby reducing the occurrence of feeding related complications such as abdominal distension, diarrhea, and nausea. Further supporting this viewpoint, early nutritional intervention following surgery was associated with reduced hypermetabolism, enhanced intestinal barrier protection, and a decline in infectious complications in a randomized clinical trial of 105 patients with digestive tract cancers[25]. In a prospective study, Martos-Benítez et al[26] demonstrated that implementing an early gastrointestinal rehabilitation program for patients undergoing surgery for GC, including pain relief, early activity, gastric protection, management of postoperative nausea and vomiting, and early nasogastric tube removal, reduced the incidence of major complications, including respiratory system complications, delirium, infections, and gastrointestinal complications. Mortality rate, length of stay in the intensive care unit, and length of hospital stay also decreased.

In conclusion, early stepwise nutritional management in postoperative patients with GC can effectively shorten the improvement time of clinical symptoms, reduce the occurrence of feeding intolerance, improve nutritional indicators, and facilitate disease recovery.

A limitation of this study is its short observation time, which makes it impossible to clarify the impact of early postoperative stepwise nutritional management on the long-term survival rate of patients after GC surgery. In the future, the observation time needs to be extended. In addition, the details of the randomization process and blinding were insufficient, increasing the risk of selection and observer bias. Furthermore, multicenter prospective experiments need to be conducted to explore the practical applications of early stepwise nutritional management.

CONCLUSION

Compared with the conventional postoperative feeding method, early stepwise nutritional management can significantly improve the nutritional status of patients with GC after surgery, improve feeding tolerance, reduce postoperative complications, and improve patient prognosis.