Dynamic assessment and standardization of enteral nutrition intolerance after gastrectomy: A prospective cohort study

Enteral nutrition intolerance (ENI) remains a major challenge in nutritional management after gastrectomy, but its definition and assessment criteria vary widely across studies. We conducted a prospective study to investigate the incidence, risk factors, biomarker dynamics, and impact on short-term recovery of ENI and to provide supporting evidence for a standardized framework for the definition of ENI.

A prospective cohort of 153 patients undergoing gastrectomy received early enteral nutrition (EEN) via a nasojejunal tube. Time to ENI was analyzed using Kaplan-Meier curves and Cox proportional hazards models (Models A-C). Propensity score-based weighting and matching analyses were performed for sensitivity testing. Generalized estimating equations (GEE) were used to evaluate postoperative longitudinal changes in biomarkers (Hb, WBC, ALB, CRP, IL-6, and PCT). Short-term recovery outcomes, including time to first flatus/defecation, length of hospital stay, in-hospital complications, and unplanned readmission within 30 d, were also compared.

ENI occurred in 44.4% of patients, with abdominal distension being the most common symptom (86.7%). In unadjusted analyses, neoadjuvant therapy appeared to be associated with a lower risk of ENI, whereas total gastrectomy was associated with a higher risk. However, after multivariable adjustment and propensity score-based sensitivity analyses, the association between neoadjuvant therapy and ENI was attenuated using inverse probability of treatment weighting (IPTW) (hazard ratio [HR] ≈ 0.98, P = 0.95), while total gastrectomy remained independently associated with ENI after full matching (HR ≈ 2.14, 95% CI 1.08-4.22, P = 0.028). GEE analysis demonstrated significant time effects for all biomarkers (P < 0.001); only albumin showed a significant group × time interaction, characterized by a faster postoperative rebound in EN-tolerant patients. ENI was associated with a prolonged hospital stay (P < 0.05), but not with time to first flatus/defecation, in-hospital complications, or unplanned readmission within 30 d.

Total gastrectomy independently increased ENI risk, while ALB dynamic trajectory, rather than its absolute value, may better reflect EN tolerance recovery. Our findings highlight the need for a standardized, time-dependent definition of ENI to improve comparability and guide individualized postoperative nutrition strategies.