Application Of En By Nasojejunal Feeding Tubes Under Gastric Cancer

Background: ERAS(enhanced recovery after surgery)is a multimodal approach designed to enhance patients' early recovery.Comparative studies between ERAS and conventional methods have been studied,and ERAS was deemed superior.Hence,ERAS protocols are widely recommended.Albeit its broad acceptance some of ERAS guidelines are difficult to comply with.However,studies concluded that specific pathways are challenging.Of note,several studies have linked malnutrition with an increase in surgical stress.Additionally,malnourished patients after gastrectomy tend to result in postoperative complications caused by diminished innate immunity,inflammatory cascades,longer durations of postoperative ileus,intestinal permeability,weakness,unstable blood glucose levels and many more nutritional complications leading to poor post-operative outcome.Postsurgical patients' oral feeding begins with clear fluids 1-3 days after surgery.This might not be sufficiently nutritious to boost the host immune system and provide adequate energy in gastric neoplastic patients.Notably,since ERAS guidelines recommend elimination of EN(enteral nutrition)feeding,no data is available on ERAS patients administered via enteral nutrition in gastric cancer.Aims: The current study is aimed at analysing available evidence from several observational cohort studies,followed by a retrospective study on the importance of feeding tubes and its benefits under ERAS guidelines.Methods: All analyses were conducted by either Review Manager(Rev-Man)5.3 and(SPSS)version 26.0.0 software(SPSS Inc.,Chicago,IL,USA).Continuous data are expressed as standard mean difference(SMD)or mean difference(MD)with 95% confidence interval(CI),and risk ratio(RR)was used to estimate the dichotomous outcomes.Random effect and fixed effect models were computed under statistical methods of either Mantel-Haenszel(for RR)or Inverse Variance(for SMD,MD)were used in the analysis of data for the meta-analysis.Test for normal or abnormal distribution of data was conducted by Kolmogorov-Smirnov test.Data with normal distribution were analyzed by one-way ANOVA or independent sample t-test and presented as(mean ± standard deviation).All the above-mentioned studies,either Metaanalysis or retrospective cohort studies,were analyzed using the respective software's.Results Meta-analysis included online data.Nine randomised trials(n = 1437)and 5 retrospective studies(n = 421)comparing enteral nutrition EN feeding tubes and parenteral nutrition PN were deemed eligible for the pooled analyses used in the analysis under a categorized time frame of PODs ? 7 and PODs < 7.Ratio of CD4+/CD8+ in EN feeding tubes was the only outcome of PODs < 7,which showed significance [MD 0.22,95% CI(0.18-0.25),P<0.00001].Regarding other immune indicators,significant outcomes in favour of EN feeding tubes were measured on POD ? 7;CD3+ [SMD 1.71,(95% CI 0.70,2.72),P=0.0009],CD4+[MD 5.84,95% CI(4.19,7.50),(P < 0.00001)],CD4+/CD8+ [MD 0.28,(95% CI 0.20,0.36),P<0.00001],NK cells [SMD 0.94,(95% CI 0.54,1.30),P<0.00001].In the retrospective cohort studies,a significant difference between the 2 groups in terms of Creatinine reactive protein CRP,interlukin-6 IL-6,platelets PLT,hemoglobin Hb,albumin,and pre-albumin levels,while WBC showed no significant difference.CRP(Mean ± SD of 12.04 ± 13.38 and 35.34 ± 38.40,p < 0.05),IL-6(Mean ± SD;59.15 ± 52.17 and 16.38 ± 14.74 p < 0.05),WBC(Mean ± SD;5.58 ± 1.68 and 6.64 ± 2.71,p = 0.07),PLT(Mean ± SD;337.22 ± 87.59 and 229.10 ± 79.47,p < 0.05),Hb(Mean ± SD;136.56 ± 18.54 and 125.33 ± 17.37,p < 0.05),Albumin(Mean ± SD;36.03 ± 4.60 and 30.32 ± 5.71;p < 0.05),postoperative pulmonary infection.Conclusion: Current ERAS guidelines suggest,patients should administer oral fluid.However,the amount of the oral diet shortly after surgery is very limited for gastric neoplastic patients as most patients are weak,undernourished and in a cancerous physique.Therefore,alternative methods to ensure the patient gets enough energy by PN and EN is imperative beyond recommendations of ERAS guidelines.The analysis performed demonstrated that EN is paramount when compared to PN additionally,combined EN and PN have better results compared to PN alone as recommended by ERAS guidelines.In summary ERAS guidelines should adopt the current modified ERAS pathways shown in this work of combined EN and PN due to its effectiveness compared to the current recommended guidelines.