Introduction
Cancer remains one of the leading causes of
mortality worldwide. Malnutrition is highly prevalent among
patients with cancer, primarily due to tumor burden, major surgical
stress, metabolic disorders, immunodeficiency and reduced dietary
intake (1). Malnutrition has been
identified as a critical factor associated with post-operative
complications and clinical outcomes in oncology patients (2).
Enhanced recovery after surgery (ERAS) is a
multidisciplinary surgical care protocol designed to improve
recovery, minimize post-operative complications, and reduce the
period of hospitalization. A key element of ERAS is the initiation
of early oral or enteral nutrition post-operatively (3-5).
Early enteral nutrition ((EEN), defined as initiating feeding
within 24 h following surgery, or 48 h in critically ill patients,
is recommended over delayed initiation (6). EEN has been shown to reduce
post-operative catabolism, promote the recovery of gastrointestinal
function, and lower the risk of developing post-operative
complications (7,8).
Currently, EEN provided within 24-48 h
post-operatively has been widely implemented in colorectal surgery,
with strong evidence of safety and efficacy from high-quality
clinical trials (9,10). Several studies have confirmed that
EEN is both feasible and safe, even when initiated on the 1st day
post-operatively. In Vietnam, some studies have reported positive
outcomes of EEN following gastrointestinal surgery (11,12).
Nonetheless, concerns about anastomotic leak and post-operative
ileus continue to lead a number of institutions to delay feeding
until the passage of flatus.
The Vietnam National Cancer Hospital (Hanoi,
Vietnam) is the leading oncology hospital in the country. However,
the implementation of EEN in patients with gastrointestinal cancer
post-operatively has not been standardized across surgical
departments. Moreover, large-scale data evaluating the outcomes of
EEN in this population in Vietnam remain limited. Therefore, the
present study was conducted to in an aim provide further evidence
to support clinical decision-making regarding the optimal timing of
EEN initiation in patients with gastrointestinal cancer
post-operatively.
Patients and methods
The present prospective descriptive study was
conducted from May to August, 2024 at the Department of
Gastrointestinal Surgery, Vietnam National Cancer Hospital.
Eligible participants were patients with gastrointestinal cancer
scheduled for surgery and indicated for EEN within 72 h
post-operatively. Initial ethics approval was obtained in April
2024. The study was officially approved by the Ethics Committee of
the Vietnam National Cancer Hospital (Decision no. 3458/QĐ-BVK,
dated November 22, 2024). This is a clinical research study that
has been approved by the hospital's ethics committee. All
participants were fully informed and provided with a thorough
explanation.
Sample size and selection of
participants
The inclusion criteria comprised adult patients
(aged ≥20 years) with a confirmed diagnoses of gastric, small
intestine, colon, or rectal cancer who were eligible for surgery
and for initiating EEN within 24-72 h post-operatively (as
determined by a consensus among the surgeon, attending physician,
and clinical nutritionist). The exclusion criteria were those with
severe hepatic, renal, or cardiac failure; emergency surgery; lack
of informed consent; non-compliance with nutritional protocols; and
an altered mental status.
Study protocol
The study protocol included the following steps: i)
Pre-operative phase: Eligible patients were interviewed, and
anthropometric measurements and laboratory tests were recorded. ii)
Post-operative phase: Patients were clinically assessed to
determine readiness for gastrointestinal function initiation based
on consensus among the surgical team. Daily follow-up monitoring
was performed. iii) Follow-up: Digestive symptoms, post-operative
complications and 24-h dietary intake were recorded for 7
consecutive days. iv) Day 7 assessment: Anthropometric indices were
reassessed, and nutritional status was evaluated using the
Patient-Generated Subjective Global Assessment (PG-SGA). v) Outcome
recording: The length of hospitalization was documented. During the
4-month study period, 469 patients underwent surgery. Of these, 190
patients were excluded due to discontinuous monitoring or
non-compliance with the nutritional protocol, and 23 patients were
excluded for commencing EEN >72 h post-operatively. A total of
256 patients were included in the final analysis.
Outcome measures and analytical tools.
Body mass index (BMI)
BMI was calculated as weight (kg) divided by height
squared (m²), as follows: Overweight/obese, BMI ≥25; normal, BMI
≥18.5 and <25; malnutrition, BMI <18.5. When the BMI is
<18.5, this indicates chronic energy deficiency (CED) and was
classified as follows: CED grade 1 (mild), BMI 17-18.49; CED grade
2 (moderate), BMI 16.0-16.99; CED grade 3 (severe), BMI <16.
PG-SGA. The PG-SGA (13) is a comprehensive tool widely used
to assess nutritional status in oncology. It incorporates multiple
factors, including the following: Unintentional weight loss,
reduced dietary intake, declined physical activity, elevated
metabolic demand (e.g., fever, corticosteroid use), and physical
examination findings such as muscle atrophy, subcutaneous fat loss,
edema and ascites. A higher PG-SGA score indicates a greater degree
of nutritional risk. The categories are as follows: Category A,
well-nourished; category B, suspected or moderate malnutrition;
category C, severe malnutrition.
Prognostic nutritional index (PNI). The PNI
was first proposed as an immune nutritional index to assess
nutritional status prior to surgery (14-16).
The PNI reflects the serum albumin levels and the total number of
lymphocytes in the blood. It is calculated as follows: PNI=10 x
albumin g/dl + 0.05 x lymphocyte count (G/L). Nutritional status
classification was as follows: PNI ≥50, normal; PNI >45 and
<50, mild malnutrition; PNI ≥40 and ≤45, moderate-to-severe
malnutrition; and PNI <40, severe malnutrition.
24-h dietary intake assessment. The
principles of postoperative nutritional support were as follows: As
per the ESPEN practical guideline on clinical nutrition in surgery,
patients with cancer undergoing surgery should receive nutrition
within an ERAS framework (3,6,17).
The energy requirements are 30-35 kcal/kg/day, the protein
requirements are 1.2-2 g/kg/day, which can be increased up to 2
g/kg/day, and vitamin and mineral are provided according to the
daily recommended intake. High-dose supplementation is discouraged
unless deficiency is confirmed.
Enteral nutrition protocol (applied in
the present study)
For the initiation of enteral nutrition, on the day
gastrointestinal feeding was initiated, patients received a clear
liquid diet consisting of thin rice porridge (finely ground rice
with added sodium chloride) or a 10% glucose solution, administered
at 100 ml per meal, three to six times daily, in combination with
parenteral nutrition to meet baseline energy requirements. On day 2
of enteral feeding, patients progressed to a transitional liquid
diet consisting of blended rice porridge (prepared with rice, lean
pork and salt), provided at 150-200 ml per meal, three times daily,
supplemented with milk (200 ml), twice daily, alongside continued
parenteral nutrition. On post-operative days 3 to 7, patients
advanced to a full liquid or soft diet, including porridge made
with rice, a protein source (pork, beef, or chicken), vegetable
oil, salt and cooked vegetables, administered at volumes ranging
from 250-500 ml per meal, three times daily. This was supplemented
with milk (200 ml), twice daily, with parenteral nutrition
continued as needed, based on individual nutritional status and
tolerance. The dietary regimen was individualized and maintained
through post-operative day 7.
Statistical analysis
The data were cleaned before and during the data
entry process. Statistical analyses were performed using SPSS v20.0
software (Dotmatics). Proportions were compared using the
Chi-squared test (χ2 test); Fisher's exact test was used
when expected values were <5. Continuous variables were compared
using the t-test (if normally distributed) or the Mann-Whitney U
test (if not normally distributed). For comparisons across ≥3
groups, otherwise, the Kruskal-Wallis test was applied followed by
the Bonferroni correction. Associations were evaluated using odds
ratios (ORs) and 95% confidence intervals (CIs). A value of
P<0.05 was considered to indicate a statistically significant
difference.
Results
Data were collected from 256 hospitalized older
patients with a mean age of 60.9±10.4 years. The baseline
demographic and clinical characteristics of the patients are
presented in Table I. Among the
types of cancer, colorectal cancer accounted for the highest
proportion (65.7%), with rectal and colon cancer comprising 33.7
and 32.0%, respectively, gastric cancer at 31.6%, and small
intestine cancer at the lowest value, with 2.7%. In terms of cancer
stage, stage III was the most common, comprising 52.3% of cases. 0.
Regarding treatment methods, 32.4% of patients received neoadjuvant
chemo-radiotherapy prior to surgery. Malnutrition was 2.4-fold more
prevalent among patients receiving neoadjuvant chemo-radiotherapy
(P<05). As regards surgical approaches, laparotomy accounted for
67.2% while laparoscopic surgery accounted for 32.8%. Among the
patients with a BMI <18.5, the proportion undergoing laparotomy
was particularly high (80.3%), with a statistically significant
difference (P<0.05). Malnutrition was significantly more common
in patients aged >70 years (OR, 2.3; 95% CI, 1.1-4.6;
P<0.05). In terms of timing for the initiation of enteral
nutrition, 50.8% of patients began oral feeding within 24 h
following surgery, 35.5% within 24-48 h and only 13.7% between
48-72 h.
 | Table IBaseline demographic and clinical
characteristics of the patients (n=256). |
Table I
Baseline demographic and clinical
characteristics of the patients (n=256).
| Characteristic | All participants
(%) | BMI <18.5
(%) | BMI ≥18.5 (%) | P-value | OR (95% CI) |
|---|
| Cancer site, n
(%) | | | | 0.083a | |
|
Stomach | 81 (31.6) | 29 (43.9) | 52 (27.4) | | |
|
Small
intestine | 7 (2.7) | 2 (3.0) | 5 (2.6) | | |
|
Colon | 82 (32.0) | 18 (27.3) | 64 (33.7) | | |
|
Rectum | 86 (33.7) | 17 (25.8) | 69 (36.3) | | |
| Stage disease, n
(%) | | | | 0.464b | |
|
I | 33 (12.9) | 6 (9.1) | 27 (14.2) | | |
|
II | 48 (18.8) | 10 (15.2) | 38 (20.0) | | |
|
III | 134 (52.3) | 37 (56.1) | 97 (51.1) | | |
|
IV | 41 (16.0) | 13 (19.6) | 28 (14.7) | | |
| Neoadjuvant
chemo-radiotherapy, n (%) | | | | 0.003b,c | |
|
No | 173(67.6) | 35 (53.0) | 138 (72.6) | | 2.4 (1.3-4.2) |
|
Yes | 83 (32.4) | 31 (47.0) | 52 (27.4) | | |
| Surgical approach,
n (%) | | | | 0.009b,c | |
|
Laparotomy | 172 (67.2) | 53 (80.3) | 119 (62.6) | | |
|
Laparoscopy | 84 (32.8) | 13 (19.7) | 71 (37.4) | | |
| History of
diabetes, n (%) | | | | 0.135b | |
|
No | 228 (89.1) | 72 (31.6) | 156 (68.) | | |
|
Yes | 28 (10.9) | 5 (17.9) | 23 (82.1) | | |
| Age group, n
(%) | | | | 0.021b,c | |
|
>70
years | 42 (16.4) | 17 (25.8) | 25 (13.2) | | 2.3 (1.1-4.6) |
|
≤70
years | 214 (83.6) | 49 (74.2) | 165 (86.8) | | |
| Mean age,
years | 60.9±10.4 | | | | |
| Time to initiation
of enteral nutrition (h), n (%) | | | | 0.061b | |
|
<24 | 130 (50.8) | 27 (40.9) | 103 (54.2) | | |
|
24-48 | 91 (35.5) | 25 (37.9) | 66 (34.7) | | |
|
48-72 | 35 (13.7) | 14 (21.2) | 21 (11.1) | | |
| All
participants | 256(100) | 66(100) | 190(100) | | |
As presented in Table
II, the average pre-operative weight of the patients was
53.2±9.7 kg, which decreased to 52.7±9.5 kg at 7 days post-surgery,
with a statistically significant reduction of 0.6 kg (P<0.05).
The prevalence of malnutrition, classified by a BMI <18.5,
increased from 25.8 to 30.1%. Nutritional status evaluated using
the PG-SGA, which indicated that pre-operatively, 83.2% of the
patients were at a nutritional risk, with 60.9% in category B
(moderate risk) and 22.3% in category C (severe risk). These
proportions increased to 67.1 and 26.6%, respectively, indicating a
progressive deterioration in nutritional status over the 7-day
post-operative period. Among the 189 patients with complete
pre-operative albumin data, the average PNI was 39.8±3.8. All
patients had a PNI <50, and 43.4% had a PNI <40, indicating
severe malnutrition.
| Table IIComparison of weight, BMI
classification, PG-SGA and PNI before and 7 days following
surgery. |
Table II
Comparison of weight, BMI
classification, PG-SGA and PNI before and 7 days following
surgery.
| Parameter | Pre-operative | Post-operative | P-value |
|---|
| Weight, kg
(n=256) | | | |
|
Mean
value | 53.2±9.7 | 52.7±9.5 | 0.001c |
|
Mean change
in weight | 0.6±3.3 | |
| BMI (n=256) | | | |
|
BMI
<18.5 | 66 (25.8%) | 77 (30.1%) | 0.001b |
|
BMI
≥18.5 | 190 (74.2%) | 197 (69.9%) | |
| PG-SGA (n=256) | | | |
|
A | 43 (16.8%) | 16 (6.3%) | 0.001a |
|
B | 156 (60.9%) | 172 (67.1%) | |
|
C | 57 (22.3%) | 68 (26.6%) | |
| PNI (n=189) | | | |
|
≥50 | 0 (0.0%) | | |
|
>45 and
<50 | 6 (3.2%) | | |
|
≥40 and
≤45 | 101 (53.4%) | | |
|
<40 | 82 (43.4%) | | |
| Mean value | 39.8±3.8 | | |
As demonstrated by the data presented in Table III, the average time to the
initiation of enteral nutrition was 34.7±16.1 h (1.4 days). By
cancer location, the earliest initiation was observed in patients
with small intestine cancer (29.1 h), followed by colorectal cancer
(31.9 h), and the longest delay was in gastric cancer cases (40.8
h), with statistically significant differences between groups
(P<0.05). The initiation time in the group receiving neoadjuvant
chemo-radiotherapy was longer than in group not receiving this
treatment (37.2 vs. 33.5 h). However, the difference was not
statistically significant (P>0.05).
| Table IIIDigestion initiation time according
to cancer location, surgical type and surgical method (n=256). |
Table III
Digestion initiation time according
to cancer location, surgical type and surgical method (n=256).
| Parameter | Time to initiate
enteral nutrition (days) | P-value |
|---|
| Cancer site | | |
|
Stomach | 40.8±18.0
(1.7) | 0.001a,b |
|
Small
intestine | 29.1±12.2
(1.2) | |
|
Colon and
rectum | 31.9±14.3
(1.3) | |
| Surgical type | | |
|
Total
gastrectomy | 40.1±18.5
(1.7) | 0.009a,b |
|
Near-total
gastrectomy | 44.3±16.7
(1.8) | |
|
Gastrojejunostomy | 40.0±15.9
(1.7) | |
|
Small
intestine resection | 21.1±12.2
(1.2) | |
|
Colon/rectum
resection | 32.0±14.7
(1.3) | |
|
Colostomy
creation | 31.5±13.3
(1.3) | |
| Pre-operative
chemotherapy and/or radiation therapy | | |
| Surgery | | |
|
Yes | 37.2±16.7
(1.5) | 0.119a |
|
No | 33.5±15.7
(1.4) | |
| Procedure | | |
|
Laparotomy | 35.4±16.5
(1.5) | 0.772a |
| p Laparoscopy | 34.0±15.9
(1.4) | |
| Overall mean | 34.7±16.1
(1.4) | |
The results of a comparison of several
characteristics between the weight loss group and the weight gain
group on post-operative day 7 are presented in Table IV. Among the 256 patients who
underwent gastrointestinal surgery included in the study, the time
to the initiation of enteral nutrition was earlier in the weight
gain group than in the weight loss group (33.3±14.3 vs. 35.4±16.9
h), with no statistically significant difference (P>0.05).
Additionally, the incidence of abdominal distension was 7.4%, and
the incidence of diarrhea was 4.7%. In terms of gastrointestinal
symptoms, abdominal distension was observed in 7.4% of patients.
Abdominal distension was associated with a markedly higher
incidence of weight loss (89.5 vs. 62.9%, P<0.05). The odds of
weight loss were 5-fold higher in patients with abdominal
distension (OR, 5.0; 95% CI, 1.1-22.2). Diarrhea occurred in 4.7%
of patients, with 83.3% experiencing weight loss, compared to 63.9%
in those without diarrhea. However, this difference was not
statistically significant (P>0.05). As regards post-operative
complications, only 1 case (0.4%) of post-operative bowel
obstruction due to ileus was recorded. This patient underwent
gastric surgery and received enteral nutrition after 48 h
post-operatively. Ileus was diagnosed on post-operative day 4. The
average length of hospitalization was 7.0±1.3 days, with no
significant differences between the two groups. As regards
post-operative dietary intake, overall energy intake did not meet
the recommended nutritional requirements. The dietary intake was
lowest on post-operative day 1 (682.9±220.7 kcal/day), peaking on
day 4 (1,370.8±310.8 kcal/day) and then slightly decreasing by day
7 (1,172.5±283.0 kcal/day). From day 3 onward, both energy and
protein intake were consistently higher in the weight gain group
compared to the weight loss group, with significant differences
from post-operative days 3 to 7 (P<0.05).
| Table IVComparison of several criteria
between the weight loss group and weight gain group 7 days
following gastrointestinal surgery. |
Table IV
Comparison of several criteria
between the weight loss group and weight gain group 7 days
following gastrointestinal surgery.
| Parameter | All
participants | Weight loss group
(n=166) | Weight gain group
(n=90) | P-value | OR (95% CI) |
|---|
| Time to initiation
of enteral nutrition (h) | 34.7±16.1 | 35.4±16.9 | 33.3±14.3 | 0.628c | |
| Digestive
symptoms | | | | | |
|
Abdominal
distension | | | | 0.019a,d | |
|
No | 237 (92.6%) | 149 (62.9%) | 88 (37.1%) | | 5.0 (1.1-22.2) |
|
Yes | 19 (7.4%) | 17 (89.5%) | 2 (10.5%) | | |
|
Diarrhea | | | | 0.224a | |
|
No | 244 (95.3%) | 156 (63.9%) | 88 (36.1%) | | 2.8 (0.6-13.1) |
|
Yes | 12 (4.7%) | 10 (83.3%) | 2 (16.7%) | | |
| Complications | | | | 0.999a | |
|
No | 255 (99.6%) | 165 (64.7%) | 90 (35.3%) | | |
|
Yes | 1 (0.4%) | 1 (100.0%) | 0 (0%) | | |
| Length of
hospitalization (days) | 7.0±1.3 | 7.1±1.5 | 6.9±1.1 | 0.204b | |
| Post-operative
daily dietary intake | | | | | |
|
Day 1 | | | | | |
|
Protein
(g/kg/day) | 0.4±0.1 | 0.4±0.0 | 0.4±0.1 | 0.087c | |
|
Energy
(kcal/kg/day) | 13.2±4.8 | 13.1±4.6 | 13.3±5.1 | 0.712c | |
|
Energy
total (kcal/day) | 682.9±220.7 | | | | |
|
Day 2 | | | | | |
|
Protein
(g/kg/day) | 0.6±0.3 | 0.6±0.3 | 0.7±0.3 | 0.021a,d | |
|
Energy
(kcal/kg/day) | 18.6±7.5 | 17.9±7.2 | 19.7±7.9 | 0.059c | |
|
Energy
total (kcal/day) | 962.7±357.5 | | | | |
|
Day 3 | | | | | |
|
Protein
(g/kg/day) | 0.9±0.3 | 0.9±0.3 | 1.0±0.3 | 0.008a,d | |
|
Energy
(kcal/kg/day) | 24.2±7.6 | 23.4±7.4 | 25.7±7.7 | 0.026a,d | |
|
Energy
total (kcal/day) | 1,256.5±344.8 | | | | |
|
Day 4 | | | | | |
|
Protein
(g/kg/day) | 1.1±0.3 | 1.0±0.2 | 1.1±0.3 | 0.001b,d | |
|
Energy
(kcal/kg/day) | 26.5±7.3 | 25.3±6.6 | 27.8±7.1 | 0.001b,d | |
|
Energy
total (kcal/day) | 1,370.8±310.8 | | | | |
|
Day 5 | | | | | |
|
Protein
(g/kg/day) | 1.1±0.3 | 1.0±0.2 | 1.1±0.3 | 0.003b,d | |
|
Energy
(kcal/kg/day) | 26.0±6.9 | 25.1±6.6 | 26.1±6.9 | 0.003b,d | |
|
Energy
total (kcal/day) | 1,346.4±285.3 | | | | |
|
Day 6 | | | | | |
|
Protein
(g/kg/day) | 1.0±0.3 | 1.0±0.2 | 1.1±0.3 | 0.026b,d | |
|
Energy
(kcal/kg/day) | 24.9±6.6 | 24.2±6.3 | 26.1±6.9 | 0.025b,d | |
|
Energy
total (kcal/day) | 1,288.8±271.6 | | | | |
|
Day 7 | | | | | |
|
Protein
(g/kg/day) | 1.0±0.3 | 0.9±0.3 | 1.0±0.3 | 0.032b,d | |
|
Energy
(kcal/kg/day) | 22.6±6.6 | 21.9±6.1 | 24.0±7.2 | 0.011b,d | |
|
Energy
total (kcal/day) | 1172.5±283.0 | | | | |
The present study then compared some of the outcomes
between diabetic and non-diabetic patients with EEN following
gastrointestinal surgery. The results are presented in Table V. The time to the initiation of
digestion was 34.9±15.3 h, with no significant difference between
the groups. The weight change following surgery was 0.8±1.9 kg in
the diabetic group, which was higher than that in the non-diabetic
group; however, this difference was not statistically significant.
Among the diabetic patients, the incidence of abdominal distension
was 3.6%, and diarrhea was reported in 7.1% of patients. No
significant differences were observed between the diabetic and
non-diabetic patients. Protein intake was comparable between the
two groups throughout the 7-day post-operative period. However, the
total energy intake in the diabetic group was consistently lower
than that in the non-diabetic group, with statistically significant
differences observed on post-operative days 1, 2, 5 and 6
(P<0.05). The proportion of energy derived from enteral
nutrition was also lower in the diabetic patients, highlighting the
need for individualized nutritional counseling and monitoring.
| Table VComparison of some characteristics
between the group of patients with diabetes and the group without
diabetes. |
Table V
Comparison of some characteristics
between the group of patients with diabetes and the group without
diabetes.
| Parameter | Non-diabetes, n=228
(89.1%) | Diabetes, n=28
(10.9%) | P-value |
|---|
| Time to initiation
of enteral nutrition (h) | 34.6±16.2 | 34.9±15.3 | 0.927c |
| Change in weight
(kg) | 0.6±3.4 | 0.8±1.9 | 0.589d |
| Digestive
symptoms | | | |
|
Abdominal
distension | | | |
|
No | 215 (94.3%) | 27 (96.4%) | 0.999a |
|
Yes | 13 (5.7%) | 1 (3.6%) | |
|
Diarrhea | | | |
|
No | 218 (95.6%) | 26 (92.9%) | 0.627a |
|
Yes | 1110 (4.4%) | 2 (7.1%) | |
| Complications | | | 0.999a |
|
No | 227 (99.6%) | 28 (100.0%) | |
|
Yes | 1 (0.4%) | 0 (0%) | |
| Length of
hospitalization (days) | 7.1±1.5 | 6.9±0.8 | 0.693c |
| Day 1 | | | |
|
Protein
(g/kg/day) | 0.4±0.1 | 0.3±0.1 | 0.163b |
|
Energy
(kcal/kg/day) | 13.5±4.7 | 10.8±4.5 | 0.004b,d |
|
% from
enteral nutrition | 2.0% | 1.5% | |
| Day 2 | | | |
|
Protein
(g/kg/day) | 0.6±0.3 | 0.6±0.2 | 0.246b |
|
Energy
(kcal/kg/day) | 19.0±7.5 | 14.8±6.4 | 0.004b,d |
|
% from
enteral nutrition | 30.8% | 22.5% | |
| Day 3 | | | |
|
Protein
(g/kg/day) | 0.9±0.3 | 0.9±0.3 | 0.635b |
|
Energy
(kcal/kg/day) | 24.5±7.5 | 21.8±8.1 | 0.070b |
|
% from
enteral nutrition | 59.4% | 53.3% | |
| Day 4 | | | |
|
Protein
(g/kg/day) | 1.1±0.3 | 1.0±0.2 | 0.198b |
|
Energy
(kcal/kg/day) | 26.8±7.3 | 23.8±6.1 | 0.087b |
|
% from
enteral nutrition | 76.7% | 72.4% | |
| Day 5 | | | |
|
Protein
(g/kg/day) | 1.1±0.2 | 1.0±0.3 | 0.037b,d |
|
Energy
(kcal/kg/day) | 26.4±6.8 | 23.6±7.2 | 0.039b,d |
|
% from
enteral nutrition | 81.5% | 77.0% | |
| Day 6 | | | |
|
Protein
(g/kg/day) | 1.1±0.3 | 1.0±0.3 | 0.055b |
|
Energy
(kcal/kg/day) | 25.2±6.6 | 22.8±6.5 | 0.023b,d |
|
% from
enteral nutrition | 82.1% | 77.0% | |
| Day 7 | | | |
|
Protein
(g/kg/day) | 1.0±0.3 | 0.9±0.3 | 0.112b |
|
Energy
(kcal/kg/day) | 22.8±6.7 | 21.0±5.8 | 0.173b |
|
% from
enteral nutrition | 82.0% | 77.0% | |
Discussion
The present study evaluated 256 gastrointestinal
cancer patients who were indicated for surgery, with an average age
of 61 years of age (60.9±10.4 years).
Postoperative weight loss
The research results indicate that the average
weight loss within 7 days following surgery was 0.6 kg (Table II) (from 53.2 to 52.7 kg). This
result is lower than what was reported in previous studies, which
observed weight loss ranging from 1.5 to 3 kg (12,18-21).
Another international study on surgical patients, primarily
gastrointestinal surgeries, demonstrated that patients experienced
an average weight loss of 4.21 kg after 2 weeks post-operatively
(22). The differences in these
results may be due to the fact that the subjects in the present
study received effective nutritional interventions and care, which
contributed to less weight loss compared to previous studies.
Nutritional status assessment
according to BMI and PG-SGA
Based on BMI, the pre-operative malnutrition rate
was 25.8%. This finding is consistent with the findings in the
studies by Thanh and Duyen, which reported rates of 26.0 and 24.5%,
respectively (18,20). This finding is also in line with
the findings in the study by Chu (12) in patients undergoing
gastrointestinal surgery, where the malnutrition rate was 33.87%.
These results underscore the importance of nutritional
interventions for surgical patients, particularly those with
gastrointestinal cancer (23). In
patients undergoing surgery for abdominal cancers, Mullen et
al (24) reported that the
mortality rate among those with a malnourished preoperative BMI was
5-fold higher than among patients with a normal weight or those who
were overweight or obese. Similarly, Hede et al (25) found that patients with colorectal
cancer with a BMI <18.5 kg/m2 had a higher 30-day
post-operative mortality rate compared to those with a BMI ≥18.5
kg/m2. In the present study, patients who underwent
neoadjuvant chemoradiotherapy had a 2.4-fold higher malnutrition
rate compared to those who did not receive pre-operative treatment.
This difference was statistically significant (P<0.05). This may
be attributed to the adverse effects of chemotherapy on the
gastrointestinal system, which can lead to anorexia and
malabsorption, thereby contributing to a decline in nutritional
status. Moreover, patients requiring neoadjuvant treatment often
present with more advanced disease, further compromising their
nutritional condition (26). In
addition, the malnutrition rate (BMI <18.5) in patients aged
>70 years was 2.3-fold higher than in those aged ≤70 years,
consistent with physiological changes associated with aging. This
result is also supported by the study by Nguyen et al
(27), which demonstrated that
individuals aged >70 years had a higher malnutrition rate
compared to younger age groups. At 7 days post-operatively, the
malnutrition rate in the present study increased to 30.1%, although
still lower than the 39.4% reported in the study by Nguyen
(18). This difference highlights
the significance of early feeding interventions for patients in
post-surgery.
Pre-operative assessment using the PG-SGA indicated
that 83.2% of the patients were classified as mildly/moderately or
severely malnourished, with 60.9% falling into mild/moderate
malnutrition (PG-SGA category B) and 22.3% into severe malnutrition
(PG-SGA category C). These rates were higher than those reported in
the 2022 study by Le et al (28) on patients with colorectal cancer,
which demonstrated that 60.9% of patients were categorized as
PG-SGA B and 8.6% as PG-SGA C. Similarly, they exceeded the
findings of the study by Diệp et al (29), which reported 55.0% in PG-SGA B and
25.7% in PG-SGA C, and those of the study by Linh et al
(30), where the overall
malnutrition rate was 56.8%. Compared to international studies,
there were also notable differences in malnutrition risk across
countries and regions. The malnutrition rate in the present study
was higher than that reported in the study by Maurício et al
(31), where 52.4% of 84 patients
undergoing rectal cancer surgery were classified as having
mild/moderate or severe malnutrition. In the present study,
following surgery, the nutritional status remained poor, with 67.1%
of patients classified as PG-SGA B and 26.6% as PG-SGA C. This
increase in malnutrition is consistent with the majority of
studies, which show a deterioration in nutritional status based on
PG-SGA following surgery (30).
Contributing factors include post-operative weight loss, a marked
decrease in dietary intake compared to pre-operative levels,
limited functional activity (e.g., difficulty walking, some
patients unable to stand), muscle atrophy and an elevated metabolic
rate. Pain at the surgical site further aggravates the condition.
These factors significantly affect PG-SGA scores following surgery,
resulting in higher proportions of patients being classified as
PG-SGA B or C. Although weight status appears improved compared to
earlier studies, other critical factors, such as anorexia,
abdominal distension and pain continue to negatively affect
post-operative nutritional status. These findings highlight the
need for ongoing nutritional intervention and monitoring, as the
nutritional status of patients may deteriorate substantially after
discharge without appropriate support (32).
Time to initiate enteral
nutrition
According to the data presented in Table III, the mean time to initiate
enteral nutrition in our study was 34.7 h (~1.4 days), notably
earlier than reported in previous domestic studies over the past
decade, where the average initiation time typically ranged from 3
to 6 days in patients receiving traditional feeding protocols. The
study by Đào et al (33)
reported a mean time to initiate enteral nutrition of 23.5 h in the
early enteral nutrition group and 60 h in the traditional feeding
group. By contrast, other studies reported a mean time to initiate
enteral nutrition of 3 to 6 days post-operatively (12,18,19,34,35).
These discrepancies may be attributed to evolving clinical
perspectives among surgeons regarding the optimal timing for
nutritional initiation, as well as the growing involvement of
clinical nutrition teams who now actively advocate for EEN. The
decision to implement early feeding, informed by updated
postoperative care guidelines, has been increasingly supported by
recent studies. International literature and recommendations
suggest that enteral nutrition can be initiated within 24-48 h
following gastrointestinal surgery without increasing the risk of
post-operative complications (6,9,36).
Furthermore, the study by Yang et al (37) confirmed that the timing of early
enteral nutrition was an independent factor that does not increase
the risk of post-operative bowel obstruction.
Some gastrointestinal symptoms
encountered following surgery
Among the 256 patients included in the present
study, 19 patients (7.4%) developed abdominal distension following
the initiation of enteral nutrition, and 12 patients (4.7%)
experienced diarrhea. These rates are considerably lower than those
reported in the study by Agrawal et al (38), in which 28.57% of 35 patients
undergoing gastrointestinal surgery receiving early enteral feeding
within 24 h developed abdominal distension. The rate of weight loss
in patients with abdominal distension was 5-fold higher than in
those without (95% CI, 1.1-22.2). Abdominal distension, considered
a marker of poor gastrointestinal tolerance, markedly influences
decisions regarding nutritional support and energy provision. This
symptom warrants close clinical monitoring to identify underlying
etiologies and guide appropriate nutritional and medical
interventions. In the present study, the incidence of diarrhea was
4.7%. This condition may contribute to an increased risk of
malnutrition and predispose patients to additional postoperative
complications. The study by Xu and Kong (39) indicated that post-operative
diarrhea in patients with colorectal cancer was associated with a
higher risk of anorectal fistula formation.
Early post-operative complications
within 7 days
In the present study, among the 256 patients
receiving early enteral nutrition, only 1 patient (0.4%)
experienced a post-operative complication within the first 7 days.
This individual developed bowel obstruction on post-operative day
4, having commenced enteral feeding on postoperative day 2. The
complication rate in the present study is markedly lower than the
rates reported in previous studies (11,12,28,30).
This difference may be attributable to the initial effectiveness of
nutritional intervention. However, the relatively short follow-up
period of 7 days in the present study may not fully capture both
early and delayed post-operative complications, thereby
underestimating the true complication rate. Accordingly, future
studies with extended follow-up durations are warranted to
comprehensively assess postoperative outcomes in gastrointestinal
cancer patients.
Dietary intake following surgery
In the present study, dietary intake during the
7-day post-operative period was assessed and found to be below the
recommended levels according to the ESPEN guidelines. Specifically,
energy intake was lowest on post-operative day 1, with an average
of 682.9±220.7 kcal/day (equivalent to 13.2±4.8 kcal/kg/day), it
peaked on day 4 at 1,370.8±310.8 kcal/day (26.5±7.3 kcal/kg/day)
and then decreased to 1,172.5±283.0 kcal/day (22.6±6.6 kcal/kg/day)
by day 7. Compared to a previous study, the nutrition intervention
group in that study achieved ~400 kcal on post-operative day 1,
nearly 1,300 kcal on day 4, and >1,600 kcal/day by day 6.
Moreover, the control group (receiving traditional feeding) had an
intake ranging from only 200 to 600 kcal over the first 6
post-operative days (11). The
study by Ho et al (40)
further supports this view, demonstrating that early enteral
nutrition significantly increased both energy and protein intake
compared to delayed initiation. When comparing the weight gain and
weight loss subgroups, the results of the present study revealed
significantly higher per-kg nutritional intake in the weight gain
group. This aligns with the physiological understanding that
adequate nutrition plays a critical role in preventing
postoperative weight loss. As regards patients with diabetes, no
statistically significant difference in protein intake was observed
between the diabetic and non-diabetic groups during the 7-day
post-operative period. However, total energy intake was
consistently lower in the diabetic group, with statistically
significant differences observed on post-operative days 1, 2, 5 and
6 (P<0.05). This difference may be attributed to a reduced
appetite or lower food intake due to elevated blood glucose levels
in the diabetic group. In the present study, the percentage of
energy from enteral nutrition (patients on a porridge or blended
porridge diet) was lower in the diabetic group compared to the
non-diabetic group. This can be explained by the fact that cancer
patients with diabetes tend to reduce their starch intake (such as
reducing their porridge portions) without increasing other
nutritional components, leading to a lower total energy intake in
the diabetic patient group compared to the other group. A study on
knowledge and dietary practices has also indicated inadequate
nutrient intake in patients with diabetes (41). A study in Vietnam evaluating 169
diabetic patients found that their nutritional energy intake was
lower than the recommended requirement (1,341.6±158.0 vs.
1,652.6±171.0 kcal/day) (41). In
addition, the diabetic group tends to experience more pain after
surgery, and the level of pain may affect their food intake.
Another study conducted on 80 patients found that the diabetic
group had a higher level of pain (assessed using the visual
analogue scale) compared to the non-diabetic group (42). This suggests that further attention
should be paid to counseling and care for diabetic patients,
ensuring they follow the nutritional care plan provided by
healthcare professionals.
Duration of hospitalization
The average duration of hospitalization in the
present study was 7.0±1.3 days. This result is lower than that in
the study by Chu (12), where the
average hospitalization duration for the intervention group was 8.3
days. The results of the present study are higher than those in the
study by Dao et al (11),
where the average hospitalization duration for the intervention
group was 6.2 days. However, the differences in hospitalization
time across studies on early enteral nutrition are relatively
small. These results are consistent with international findings
suggesting that early initiation of enteral nutrition following
gastrointestinal surgery may contribute to a shortened length of
hospitalization, particularly when compared to conventional delayed
feeding approaches (43,44). These findings further support the
positive impact of early enteral nutrition on clinical recovery in
patients undergoing gastrointestinal cancer surgery.
Despite the valuable insight provided by the present
study, several limitations should be acknowledged. First, the
sample size was limited to a single hospital, which may restrict
the generalizability of the findings to other populations or
clinical settings. Second, due to the short follow-up period,
long-term post-operative nutritional outcomes could not be
evaluated. Third, although the authors considered potential
confounding factors, such as cancer stage and surgical approach
during the study, the data collection did not ensure a balanced
distribution of patients across subgroups, such as cancer stages
(I-IV) or the six different surgical techniques included in the
study. Consequently, the authors intend to conduct a larger-scale,
more comprehensive investigation in the future to better control
for these confounding variables, as recommended. In the future, the
authors also plan to implement multicenter randomized controlled
trials with extended intervention and follow-up periods to
comprehensively assess early and late post-operative
complications.
Despite these limitations, the findings presented
herein support the implementation of early gastrointestinal
nutrition protocols for patients undergoing surgery for gastric,
small intestinal, or colorectal cancer in particular, and for
gastrointestinal cancers in general. This practice should be
applied systematically and proactively to improve the outcomes of
patients. Moreover, the combination of enteral and parenteral
nutrition should be carefully tailored to meet recommended
nutritional requirements. Special attention should be paid to
patients with a history of diabetes, those aged >70 years, or
those who have received neoadjuvant chemo-radiotherapy.
In conclusion, the average gastrointestinal
initiation time has met the recommended early feeding timeframe
according to the ERAS program. Patients who received neoadjuvant
chemoradiotherapy and those aged >70 years exhibited a higher
risk of malnutrition. Abdominal distension was associated with a
significantly greater risk of weight loss. Patients who have
undergone gastrointestinal surgery and also have diabetes have
lower nutritional levels compared to those without diabetes. The
average nutritional intake for patients receiving early feeding in
Vietnam still does not meet the recommended requirements according
to ESPEN. This further emphasizes the importance of early feeding
and nutritional interventions for general cancer patients and
cancer patients with diabetes specifically.
Acknowledgements
Not applicable.
Funding
Funding: No funding was received.
Availability of data and materials
The data generated in the present study may be
requested from the corresponding author.
Authors' contributions
TTT, BVH and HTL were involved in the
conceptualization of the study. TTT was involved in data curation
and in project administration. TTT and THTN were involved in formal
analysis and in data analysis. TTT, BVH and HTL were involved in
the study methodology, in data validation and supervised the study.
TTT, THTN and BVH were involved in the writing and preparation of
the original draft of the manuscript. TTT, BVH, HTL and THTN were
involved in the writing, review and editing of the manuscript. TTT
and BVH confirmed the authenticity of the raw data. All authors
have read and agreed to the published version of the
manuscript.
Ethics approval and consent to
participate
Initial ethics approval was obtained in April 2024.
The study was officially approved by the Ethics Committee of the
Vietnam National Cancer Hospital (Decision no. 3458/QĐ-BVK, dated
November 22, 2024). This is a clinical research study that has been
approved by the hospital's ethics committee. All participants were
fully informed and provided with a thorough explanation.
Patient consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing
interests.
Use of artificial intelligence tools
During the preparation of this work, AI tools were
used to improve the readability and language of the manuscript or
to generate images, and subsequently, the authors revised and
edited the content produced by the AI tools as necessary, taking
full responsibility for the ultimate content of the present
manuscript.
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