In the present study, the prevalence of preoperative malnutrition in elderly patients undergoing gastrectomy was 31.3%, which was relatively high compared with that in previous studies . The observed differences in malnutrition prevalence could be attributed to several factors, including instruments, age distribution, hospital location, and patient characteristics. Compared with well-nourished patients, those with preoperative malnutrition were associated with low levels of albumin, prealbumin, and hemoglobin. Furthermore, malnourished elderly patients were associated with higher postoperative complications and prolonged length of hospital stay compared with well-nourished patients. There was no significant difference in composition and timing of postoperative nutritional management between malnourished and well-nourished patients.
Malnutrition is one of the most crucial risk factors for postoperative complications . In elderly GC patients, malnutrition is often caused by frailty, absorption disorder, and a decrease in food intake . These patients often develop anemia, hypoproteinemia, and electrolyte abnormalities before surgery. Therefore, screening and assessment of malnutrition is an important step for all patients scheduled for major gastrointestinal surgery. Preoperative PNI is an independent prognostic factor for disease-free survival along with age and TNM stage in GC patients after surgery , and measurement of albumin and lymphocyte count is simple and convenient.
The guidelines of both the American Society for Parenteral and Enteral Nutrition (ASPEN) and ESPEN recommend oral or enteral feeding whenever possible [14, 15]. Enteral nutrition is preferred over parenteral nutrition because of a lower incidence of SSI . However, in patients with a pyloric obstruction or inadequate energy supply by enteral nutrition, peripheral parenteral nutrition or TPN is often performed . In our study, the rate of preoperative TPN in patients with malnutrition was significantly higher than that in well-nourished patients. However, the total rate of preoperative parenteral nutrition support was still low (43.5%) in patients with malnutrition. Optimal preoperative management for elderly patients with malnutrition is essential to improve surgical outcomes.
Although early initiation of oral or enteral feeding has been recommended to improve clinical outcomes and reduce surgical complications in GC patients following gastrectomy [14, 17], the postoperative nutritional support for patients is quite variable between different surgical teams. In the statement of the Japanese Gastric Cancer Treatment Guideline, the drink should be offered after postoperative day 1 and a solid diet should begin from postoperative day 2 to 4 regardless of the type of surgery . In this study, the median duration of parenteral nutrition was 5 days. Meanwhile, 54.8% of patients received only carbohydrates with or without composite amino acids postoperatively. No significant difference was found between malnourished and well-nourished groups in terms of duration. It might take some time before patients with malnutrition are properly stabilized. This study also supported the findings of previous studies that patients with malnutrition have a higher rate of overall postoperative complications [11, 19]. This indicated that elderly patients with malnutrition require close attention during the postoperative period, and nutritional support should be individualized for this vulnerable cohort.
Multivariate analysis showed that older age, longer duration of surgery, and postoperative complications were significantly associated with delayed discharge, which was consistent with previous studies . This suggested that the length of surgery could be regarded as a reliable marker of surgical stress burden, and patients undergoing a long period of surgery need special care postoperatively.
To the best of our knowledge, this is the first study to assess the nutritional status and risk factors associated with delayed discharge among geriatric GC patients in China, using a large sample size. Due to its retrospective nature, this study has several limitations. The current study did not include long-term follow-up data, and the relationship between perioperative nutritional support and clinical outcomes among malnourished patients was not explored. Further large multicenter prospective randomized controlled trials should be conducted to validate our findings.