Perioperative nutritional nursing interventions: Impact on wound healing, infection rates, and recovery indicators after gastric cancer surgery

Abstract

BACKGROUND

Postoperative complications of gastric cancer (GC) surgery often delay recovery and adversely affect patient outcomes, especially in patients predisposed to malnutrition. Poor nutritional status has been reported to affect wound healing, predispose patients to infection, and prolong hospital stay. Perioperative nutritional nursing interventions may, therefore, be an essential factor in enhancing recovery after surgery; however, research investigating their effectiveness in patients undergoing GC surgery is limited.

AIM

To assess the effectiveness of perioperative nutritional nursing interventions on wound healing, infection rate, and recovery after GC surgery.

METHODS

Clinical data of 160 patients who underwent surgery for GC between January 2023 and January 2025 were retrospectively analyzed. The patients were categorized into two groups: Intervention [structured perioperative nutrition nursing interventions (n = 80)] and control [standard perioperative care (n = 80)]. Major assessments included wound healing, incidence of surgical site infections (SSIs), length of hospital stay, and time to resumption of normal activities. Statistical comparisons were performed using the independent samples t-test and χ² test (P < 0.05).

RESULTS

Compared with patients in the control group, patients who received perioperative nutritional care intervention had better wound healing, a lower incidence of SSI (8.7% vs 15.0%, P = 0.042), a shorter hospital stay (10.5 days vs 13.2 days, P < 0.001), and a higher proportion of patients who could resume daily activities within 4 weeks (75% vs 60%, P = 0.043). Caution is required when interpreting these results because of the small sample size and limited number of infection cases.

CONCLUSION

A standardized perioperative nutritional care intervention can significantly promote wound healing, shorten hospital stay, and help patients recover their daily activities earlier, supporting its inclusion in routine perioperative care.

Key Words: Perioperative nutrition interventions; Gastric cancer; Wound healing; Infection rates; Recovery indicators; Surgical recovery; Nutritional nursing care; Hospital stay; Post-surgery recovery; Infection prevention

Core Tip: This retrospective cohort study investigated the efficacy of structured perioperative nutritional nursing interventions in patients undergoing gastric cancer surgery. Analyzing data from 160 patients, it compared outcomes between an intervention group (n = 80) and a standard care control group (n = 80). Results demonstrated that the intervention significantly improved wound healing, reduced surgical site infection rates, and shortened hospital length of stay. Furthermore, it facilitated earlier resumption of daily activities. The study concludes that integrating targeted nutritional nursing into perioperative care enhances postoperative recovery, advocating for its routine clinical implementation.

INTRODUCTION

Gastric cancer (GC) is one of the most common cancers worldwide and a leading cause of cancer-related mortality. Surgery, particularly gastrectomy, remains the primary treatment modality for localized GC. Despite advances in surgical techniques, GC surgery is still associated with postoperative complications, including poor wound healing, infections, and prolonged healing[1]. These complications not only hinder recovery but also adversely affect patients’ quality of life, prolong hospitalization, and increase healthcare costs.

A few studies have suggested that nutritional status plays a critical role in postoperative recovery, particularly among patients who have undergone major surgeries[2,3]. Patients with cancer, including those with gastric malignancies, are especially susceptible to malnutrition due to both the disease itself and its treatment, which can complicate therapeutic outcomes[4,5]. Nutritional interventions may help maintain immune function, promote tissue repair, and reduce the risk of infection, all of which contribute to improved postoperative recovery outcomes[6,7].

Although the beneficial effects of nutrition on surgical recovery have been well established, the specific contribution of perioperative nutritional nursing interventions in patients undergoing GC surgery has not been fully investigated[8,9]. While the importance of perioperative nutrition has been recognized in the literature, the effectiveness of structured nutritional nursing interventions—particularly targeted nutritional care delivered by nurses—on wound healing, infection rates, and other recovery outcomes in patients with GC remains unclear.

Therefore, this study aimed to evaluate the effects of perioperative nutritional nursing interventions on surgical outcomes, including wound healing, infection rates, and recovery indicators, in patients undergoing GC surgery. We hypothesized that patients receiving perioperative nutritional support would experience faster wound healing, lower infection rate(s), and shorter recovery times than those who did not receive such interventions.

MATERIALS AND METHODS

Study design

This single-center retrospective cohort study was conducted at the Department of General Surgery at Xi’an Ninth Hospital. The research protocol was approved by the Medical Ethics Committee of Xi'an Ninth Hospital (Approval No. 26028). Given the retrospective nature of the study, only de-identified existing medical records were analyzed, and no additional interventions, risks, or burdens were imposed on the patients. Therefore, the Medical Ethics Committee of Xi'an Ninth Hospital waived the requirement for written informed consent.

Study population and grouping

The medical records of consecutive patients who underwent radical gastrectomy for GC at our hospital between January 2023 and January 2025 were retrospectively analyzed. A total of 160 patients were ultimately included in the analysis. Eligible patients were divided into two groups according to the perioperative care they received: The intervention group (n = 80) received structured perioperative nutritional nursing interventions in addition to standard care, whereas the control group (n = 80) received standard perioperative care alone without specialized nutritional interventions.

Inclusion criteria: (1) Age ≥ 18 years; (2) Histopathologically confirmed primary GC; (3) Underwent elective curative gastrectomy (R0 resection); and (4) Complete medical records available for all outcome indicators.

Exclusion criteria: (1) Emergency surgery; (2) Severe comorbidities that could substantially affect nutritional status (e.g., end-stage renal disease, liver failure, and uncontrolled diabetes with severe complications); (3) Preoperative malnutrition receiving formal nutritional support prior to admission; or (4) Incomplete clinical or follow-up data.

Intervention protocol

Perioperative nutritional care was incorporated into the routine clinical management of the intervention group. The intervention plan was developed based on the 2021 guidelines of the European Society for Clinical Nutrition and Metabolism regarding perioperative nutrition in gastrointestinal surgery[10].

Intervention group (n = 80): In addition to standard perioperative care, the patients received a structured nutritional nursing protocol. The protocol included: (1) Preoperative nutritional assessment: Within 48 hours of admission, a trained nurse assessed each patient’s nutritional status using the Nutritional Risk Screening 2002 (NRS-2002) tool. Patients with an NRS-2002 score ≥ 3 were classified as being at nutritional risk[11]; (2) Preoperative nutritional supplementation: For patients with nutritional risk (NRS-2002 score ≥ 3 points), oral nutritional supplements (ONS) were administered starting 5.4 ± 2.3 days before the operation (mean ± SD; median 5 days, interquartile range 4-7 days)[12]. The daily nutritional targets, calculated by a registered dietitian, were 25-30 kcal/kg of actual body weight and 1.2-1.5 g/kg of protein[10]. Each ONS provided approximately 200-300 kcal and 10-15 g of protein and was taken three times daily between meals. This study did not use immune nutrition formula preparations containing arginine, ω-3 fatty acids, glutamine, etc.; and (3) Postoperative nutritional management: All patients in the intervention group resumed oral intake according to a standardized protocol: Clear liquids were initiated within 24-48 hours postoperatively, after confirmation of bowel sound recovery[12]. Full oral nutrition (soft diet) was typically resumed on postoperative day 7 (range: 5-10). ONS was continued postoperatively using the same energy and protein targets. Early enteral nutrition (via a nasojejunal tube or jejunostomy) was not routinely used in this study; all nutritional support was provided via the oral route using ONS and dietary counseling.

Role of nursing staff: Nurses in the intervention group were responsible for the following tasks: (1) Assessment: Conducting NRS-2002 screening within 48 hours of admission, and reassessing nutritional status every 3 days during hospitalization; (2) Monitoring: Daily dietary intake (type and amount of food/ONS consumed) was recorded using a standardized food diary; (3) Adjustment: Communicating with the dietitian to adjust nutritional plans if patients consumed < 60% of the prescribed intake for 2 consecutive days; and (4) Education: Provide preoperative and postoperative dietary counseling to patients and caregivers, including the importance of protein intake, wound healing, and infection prevention.

Control group (n = 80): Patients in the control group did not receive a structured nutritional nursing protocol. Their nutritional management consisted of routine hospital meals (standard menus without individualized adjustments). General postoperative dietary advice (e.g., “eat a balanced diet” and “increase protein intake”) was provided by ward nurses as part of routine discharge instructions. No systematic nutritional risk screening, ONS prescription, nurse-led dietary monitoring, or individualized counseling was provided.

Data collection

Clinical data were retrospectively extracted from electronic medical records using a standardized data collection form. Two trained research nurses independently extracted the data, and any discrepancies were resolved through discussion with a third investigator (corresponding author).

Surgical-related variables: The following surgery-related characteristics were extracted from each patient’s surgical records.

Surgical approach: Open gastric resection and laparoscopic gastric resection.

Scope of removal: Total and distal gastric resection. These variables were regarded as potential confounding factors and were included in the multivariate analysis.

Variables and outcome measures

The baseline variables included age, sex, tumor stage (stage I/II), surgical method (open surgery vs laparoscopic surgery), extent of resection (total gastrectomy vs distal gastrectomy), and preoperative nutritional status [body mass index (BMI), serum albumin level, and NRS-2002 score, when available]. Patients with a BMI < 18.5 kg/m², a serum albumin level < 35 g/L, or NRS-2002 score ≥ 3 were classified as having poor nutritional status. These variables were compared between the groups to assess baseline comparability.

Wound healing time: This was defined as the number of days from surgery until complete wound closure, as assessed by the attending surgeon.

Surgical site infection: Surgical site infection (SSI) was defined according to the Centers for Disease Control and Prevention criteria and included both superficial and deep incisional infections[13,14]; the incidence was recorded as percentage (%).

Length of hospital stay: This was defined as the number of days from surgery to discharge.

Postoperative recovery indicators: The following objective parameters were extracted from medical records to assess postoperative recovery: (1) Time to first ambulation: The number of days from surgery to the first instance of independent ambulation (with or without assistance) for at least 5 minutes, as documented by the nursing staff; (2) Time to first flatus: The number of days from surgery to the first passage of flatus, as recorded by either the patient or the nursing staff; (3) Time to nutritional target achievement: The number of days from surgery until the patient consumed ≥ 60% of the prescribed energy target (25-30 kcal/kg/day) for two consecutive days, as calculated from daily dietary records maintained by the nursing staff; (4) Length of hospital stay: The number of days from surgery to hospital discharge; and (5) Resumption of normal activities at 4 weeks: This was assessed during the 4-week postoperative follow-up visit by a trained nurse using the Barthel Index of Activities of Daily Living. A score ≥ 95 (out of 100) was considered indicative of independence in daily activities. If the Barthel Index was unavailable, the patient's ability to independently perform 5 basic activities (walking, bathing, dressing, transferring, and eating) was used as a proxy and assessed using a structured checklist.

Statistical analysis

Information obtained from the patient records was analyzed using SPSS version 26 (IBM Corp, Armonk, NY, United States). As this was a retrospective study, descriptive statistics were initially used to summarize the demographics of the study population, including age, sex, cancer stage, and other factors of interest. This provided a general picture of the patient cohort, which was critical to ensure objective comparability between the intervention and control groups at baseline.

Independent t-tests were used to compare the means of continuous variables such as time to wound healing and length of hospital stay between the intervention and control groups. These variables were assumed to be normally distributed, indicating that parametric testing could be used. The t-tests were used to compare differences in recovery outcomes between the intervention and control groups. In particular, the comparison of the time to wound healing and length of hospital stay in both groups served to determine the effectiveness of perioperative nutritional interventions.

In the case of categorical variables, more specifically, SSI incidence (both superficial and deep), χ² tests were used to compare the differences between infection rates in the groups. The χ² test was used to assess the relationship between nutritional intervention and postoperative infections. Differences with P < 0.05 were considered to be statistically significant, indicating that nutritional interventions probably affected the results.

Moreover, the confidence intervals (CIs) of the essential results (e.g., wound healing time and infection rate) were calculated to determine the accuracy of the estimates. A post hoc analysis was performed where necessary to investigate any other factors that may have affected the main results. Because this study had a retrospective design, the possibility of confounding factors was considered. To correct for this, multivariate regression analysis was performed to correct the results due to baseline differences between the groups and make the results robust.

All statistical tests were two-tailed, and differences with P < 0.05 were considered to be significant. Analyses were performed to determine the effectiveness of perioperative nutritional nursing interventions in enhancing postoperative recovery among patients with GC and in decreasing the risk of postoperative complications, including wound infections.

To correct for confounding bias caused by surgery-related factors, this study employed multivariate logistic regression analysis for the SSI outcome and multivariate linear regression analysis for the length of hospital stay and other continuous rehabilitation indicators. The covariates included in the model were age, sex, tumor stage, surgical approach (open surgery vs laparoscopic surgery), and resection range (total vs distal gastrectomy). The adjusted odds ratios (OR) and 95%CI were calculated for binary outcomes, and the adjusted mean differences and 95%CI were calculated for continuous outcomes.

The statistical methods of this study were reviewed by [name(s) of individual(s)] from [name(s) of organization(s)].

RESULTS

Comparison of baseline characteristics between intervention and control groups

This study included 160 patients who underwent surgery for GC. They were divided into intervention and control groups: 80 patients in the intervention group (60 males and 20 females), 80 patients in the control group (58 males and 22 females). The average age of the patients in the intervention group and the control group was 62.5 ± 8.2 years and 62.3 ± 8.0 years, respectively. No statistically significant differences were noted between the two groups in terms of age, sex, tumor stage, baseline nutritional status (BMI, serum albumin, and the proportion of patients with NRS-2002 score ≥ 3), surgical method (open surgery vs laparoscopic surgery), and resection range (total gastrectomy vs distal gastrectomy; all P > 0.05). This suggested that the baseline data of the two groups were comparable. Detailed baseline data are summarized in Table 1.

Table 1 Baseline characteristics of the study population.

Variable	Intervention group (n = 80)	Control group (n = 80)	t/χ2 value	P value
Age (year)	62.5 ± 8.2	62.3 ± 8.0	0.23	0.73
Sex (male/female)	60/20	58/22	0.42	0.51
Tumor stage (I/II)	42/38	44/36	0.31	0.62
BMI (kg/m2)	22.5 ± 3.2	22.8 ± 3.5	0.56	0.58
Serum albumin (g/L)	38.5 ± 4.2	38.2 ± 4.5	0.44	0.66
NRS-2002 score ≥ 3, n (%)	45 (56.3)	42 (52.5)	0.23	0.63
Surgical approach (open/Laparoscopic)	45/35	48/32	0.23	0.63
Extent of resection (total/distal)	38/42	40/40	0.10	0.75

BMI: Body mass index; NRS-2002: Nutritional Risk Screening 2002.

Comparison of wound healing outcomes

The patients in the intervention group experienced significantly faster wound healing than those in the control group. The mean time to complete wound closure in the intervention group was 14.3 ± 3.5 days, significantly lower than the 18.6 ± 4.2 days in the control group (t = 5.87, P < 0.001). These results suggest that perioperative nutritional nursing interventions significantly improve wound healing outcomes in patients undergoing surgery for GC. A detailed comparison of the wound healing times between the two groups is presented in Table 2 and Figure 1.

Figure 1 Incidence of surgical-site infection in the two groups.

Table 2 Comparison of wound healing time between the two groups, mean ± SD.

Group	Wound healing time (day)	t value	P value
Intervention group	14.3 ± 3.5	5.87	< 0.001
Control group	18.6 ± 4.2	-	-

Comparison of SSI rates

SSI incidence was 8.7% (7/80) in the intervention group and 15.0% (12/80) in the control group (χ² = 4.12, P = 0.042), suggesting that nutritional nursing intervention might be beneficial; however, the accuracy of this result is limited due to the small number of cases. Moreover, given the small sample size and limited number of SSI cases (7 in the intervention group and 12 in the control group), the conclusions of this study should be interpreted with caution. Large-scale prospective studies are needed to verify whether the observed decrease in infection rates can be replicated and whether it is statistically reliable. Detailed infection data are summarized in Table 3.

Table 3 Comparison of surgical-site infection incidence between the two groups.

Group	SSI cases (n)	SSI incidence (%)	χ2 value	P value
Intervention group	7/80	8.7	4.12	0.042
Control group	12/80	15.0	-	-

Independent samples t-test was used for between-group comparison. SSI: Surgical site infection.

Comparison of postoperative recovery indicators

The recovery indicators in the intervention group were significantly better than those in the control group (Table 4). Specifically, the time for the first post-bed activity (2.1 ± 0.8 days vs 3.5 ± 1.2 days, t = 5.67, P < 0.001), the time for the first defecation (2.8 ± 0.9 days vs 4.2 ± 1.5 days, t = 6.12, P < 0.001), and the time required to reach the nutritional target (4.5 ± 1.3 days vs 6.8 ± 2.1 days, t = 7.45, P < 0.001) were all shorter in the intervention group. The average length of hospital stay in the intervention group was also significantly shorter (10.5 ± 2.3 days vs 13.2 ± 3.1 days, t = 6.01, P < 0.001). Moreover, at 4 weeks postoperatively, the proportion of patients who reached the standard of self-care ability (Bar index ≥ 95 points) was higher in the intervention group (75% compared with 60%, χ² = 4.08, P = 0.043). These results indicate that perioperative nutritional intervention not only accelerates the early physical recovery of patients after surgery but also helps them regain their ability to perform daily self-care more quickly.

Table 4 Comparison of postoperative recovery indicators between the two groups.

Recovery indicator	Intervention group (n = 80)	Control group (n = 80)	t/χ2 value	P value
Time to first ambulation (day)	2.1 ± 0.8	3.5 ± 1.2	5.67	< 0.001
Time to first flatus (day)	2.8 ± 0.9	4.2 ± 1.5	6.12	< 0.001
Time to nutritional target achievement (days)	4.5 ± 1.3	6.8 ± 2.1	7.45	< 0.001
Length of hospital stay (days)	10.5 ± 2.3	13.2 ± 3.1	6.01	< 0.001
Barthel Index ≥ 95 at 4 weeks	60/80 (75)	48/80 (60)	4.08	0.043

Values are expressed as mean ± SD or n (%). Between-group comparisons were performed using independent t-tests for continuous variables and χ² test for the categorical variable.

DISCUSSION

The improved wound healing observed in the intervention group is consistent with previous studies that reported an association between adequate nutritional support and better tissue repair outcomes after major gastrointestinal surgery[15]. A randomized controlled trial conducted by Farreras et al[16] clearly demonstrated that for patients undergoing GC surgery, the early use of an enteral immunonutritional preparation containing arginine, ω-3 fatty acids, and ribonucleic acid after surgery significantly increased the deposition of hydroxyproline in the wound fluid (59.7 nanomoles vs 28.0 nanomoles, P = 0.0018), while reducing the incidence of wound-related complications (0% vs 26.7%, P = 0.005). Similarly, a recent study by Zhu et al[17] demonstrated that comprehensive nutritional support can significantly shorten the wound healing time of patients undergoing gastrointestinal surgery and reduce the incidence of infections, thereby confirming the role of perioperative nutritional interventions in promoting tissue repair. Patients with GC are susceptible to malnutrition, especially because of metabolic alterations caused by the tumor(s), decreased oral consumption, and postoperative stress. Operational nutritional interventions can be used to address nutritional deficiencies and enhance cell repair and wound healing. These results are consistent with the conclusions of several previous clinical trials. Previous experiments have confirmed that good nutritional status is associated with improved wound healing after major gastrointestinal surgeries[18,19].

The incidence of SSI was significantly lower in the intervention group than in the control group (8.7% vs 15.0%), which is consistent with previous research findings. Studies have shown that optimizing perioperative nutrition can reduce the incidence of postoperative infectious complications[16]. A systematic review and meta-analysis that included 19 randomized controlled trials (with a total sample size of 2047 cases) indicated that standardized perioperative nutritional therapy could reduce the risk of infection complications (relative risk = 0.67, 95%CI: 0.51-0.87)[20]. However, the number of SSI cases in the present study was relatively small (7 cases vs 12 cases), and the overall sample size was limited (n = 160). Therefore, although the difference between the groups was statistically significant (P = 0.042), the findings should be interpreted with caution. The CI for the risk difference was relatively wide, suggesting limited precision of the estimate. Consequently, the observed association may not be robust in smaller subgroups or other study populations. In summary, this study’s results can only be used to propose research hypotheses and cannot be regarded as definitive conclusions. Further large-scale randomized controlled trials are needed to determine whether perioperative nutritional nursing interventions can effectively reduce the incidence of SSI in patients undergoing GC surgery.

In the present study, the length of hospital stay in the intervention group was significantly reduced, and the recovery period for normal activities was shorter than that in the control group. Reduced length of hospitalization is not only an indicator of better physical recovery but also has significant implications for lowering the cost of healthcare and resource use. These findings are consistent with those of previous studies demonstrating that perioperative nutritional support can improve functional recovery and quality of life in patients with cancer during the postoperative phase[21,22]. In the present study, the patients recovered their daily activities earlier and had shorter hospital stays. These findings are consistent with those reported by Han et al[23]. In their randomized controlled trial involving 100 patients with stage II or III GC, Han et al[23] confirmed that the problem-oriented nursing model combined with early enteral nutrition intervention could significantly shorten the time for the first flatus, getting out of bed, defecation, and the hospital stay (Cohen's d values were 1.93, 1.24, 1.49, and 1.57, respectively). At the same time, the total incidence of complications was lower (OR = 6.00), and patient satisfaction was higher (OR = 0.17). Furthermore, existing literature reports on multicenter randomized controlled trial protocols for ONS following GC surgery provide a research foundation for elucidating how simple nutritional supplements can mitigate post-gastrectomy weight loss, improve patient medication adherence, and enhance the quality of life[24,25].

Preoperative nutritional status is a known predictor of postoperative outcomes. In this study, there were no significant differences in the baseline indicators (including BMI, serum albumin, and NRS-2002 score) between the intervention and control groups. This indicates that the benefits of the nutritional care intervention cannot be largely explained by the difference in baseline nutritional levels between the two groups.

The selection of laparoscopic vs open surgery, as well as surgical factors such as total gastrectomy vs distal gastrectomy, has been proven to affect the incidence of postoperative infections and the speed of postoperative recovery. In this study, the distribution of these variables in the intervention and control groups was similar (Table 1), thereby reducing the risk of confounding bias. However, owing to the retrospective nature of the study design, it is impossible to completely rule out the possibility that some differences in the complexity of the surgeries (such as operation duration, intraoperative blood loss, and the surgeon’s clinical experience) that were not included in the statistics may have affected the final observation results. In future prospective studies, all surgery-related covariates should be fully collected, and propensity score-matching methods should be used to further correct such confounding factors.

Limitations

This study has some limitations. First, this was a single-center retrospective cohort study, which inherently has the potential for selection bias and cannot fully control confounding variables. Although the baseline data of the two groups of patients (including age, sex, tumor stage, BMI, albumin level, NRS-2002 score, surgical approach, and resection range) were comparable, this study failed to correct for factors not included in the detection, such as differences in comorbidities, compliance with nutritional plans, and individualized differences in postoperative care plans. Second, these nutritional intervention measures were implemented as part of routine clinical practice. The intervention effects were influenced by the availability of certified nutritionists and nursing staff, which may also make it difficult for the research conclusions to be applied to other clinical scenarios. Third, this study did not measure immune- and inflammation-related indicators (such as C-reactive protein, white blood cell count, and prealbumin); thus, it was impossible to directly verify the immunomodulatory mechanism proposed by nutritional support. Fourth, although the difference in SSI incidence was statistically significant (8.7% vs 15.0%, P = 0.042), the absolute number of SSI cases was relatively small (7 cases in the intervention group and 12 cases in the control group), and the overall sample size was limited (n = 160). Therefore, the estimated results of the treatment effect are not sufficiently stable, and the risk of a type I error cannot be completely ruled out. This study’s results can only be used to propose research hypotheses and cannot be regarded as a definitive conclusion. Finally, owing to the lack of long-term follow-up data, it was impossible to assess the impact of perioperative nutritional care interventions on patients' long-term survival rate, tumor recurrence, and quality of life. A large-scale multi-center randomized controlled trial is needed to fully demonstrate these findings and determine the optimal composition, timing, and duration of perioperative nutritional support.

CONCLUSION

This study provides clinically significant evidence that systematic perioperative nutritional care intervention can significantly improve the postoperative outcomes of patients undergoing radical gastrectomy for GC, including a 4.3-day reduction in wound healing time, a 6.3% decrease in SSI rate, a 2.7-day shortening of hospital stay, and a 15% increase in the proportion of patients returning to normal activities within 4 weeks. These findings strongly support the inclusion of systematic nutritional care in the routine perioperative care of patients with GC and highlight the crucial role of multidisciplinary collaboration among nurses, dietitians, and surgeons in optimizing surgical outcomes. Medical institutions should implement standardized perioperative nutritional care plans for patients with GC, including routine nutritional risk screening, individualized dietary planning, and multidisciplinary collaboration among nurses, dietitians, and surgeons. In addition, patient education and caregiver involvement should be strengthened to improve adherence to nutritional recommendations and enhance patient compliance.