Gastric cancer remains a significant global burden, accounting for over one million new cases and approximately 770, 000 deaths annually [1]. Although declining in incidence in high-income nations, it continues to be prevalent in low- and middle-income countries, including India [2]. Indian data indicate marked regional variation, with higher incidence in southern and northeastern states due to dietary habits and persistent Helicobacter pylori infection [3, 4]. Malnutrition is seen in up to 80% of gastric cancer patients at diagnosis [5]. Tumour-related obstruction, anorexia, systemic inflammation, and altered metabolism contribute to weight loss and muscle wasting [6]. Surgical resection further aggravates these issues by disrupting normal gastrointestinal continuity and delaying oral intake. Thus, adequate perioperative nutritional support is fundamental to optimizing recovery, wound healing, and immune function [7, 8]. Enteral nutrition (EN) is preferred over parenteral feeding as it preserves gut integrity, reduces bacterial translocation, and lowers infectious complications [9, 10]. According to ERAS protocols, early postoperative EN within 24-48 h is recommended to minimize catabolic response and enhance recovery [9]. Two common routes of postoperative EN are nasojejunal (NJ) feeding and feeding jejunostomy (FJ). NJ feeding, performed via a transnasal tube advanced to the jejunum, is simple and non-invasive but may be prone to displacement or blockage. FJ, placed intraoperatively, provides secure access for longer-term nutrition but carries risks of infection, leakage, and tube-site complications [11-13]. Indian data comparing these techniques are limited. Studies by Deepjyoti et al. and Ravikumar et al. have suggested comparable nutritional efficacy but higher complication rates with FJ [14, 15]. This study was designed to prospectively compare NJ and FJ feeding routes in gastric cancer patients, focusing on safety, efficacy, and patient comfort in a resource-constrained setting.

Study Design and Setting A prospective observational study was carried out from April 2024 to March 2025 in the Department of Surgical Gastroenterology at a tertiary teaching hospital in Eastern India. Institutional ethical approval was obtained, and informed consent was taken from all participants. Patient Selection Eligible participants were adults (≥18 years) undergoing subtotal or total gastrectomy with curative intent for histologically confirmed gastric carcinoma. Exclusion criteria: pregnant or lactating women, patients with inoperable malignancy, or those undergoing palliative resection for obstruction or bleeding. Group Allocation Participants were assigned intraoperatively based on anatomical feasibility: • Group A: Nasojejunal (NJ) feeding • Group B: Feeding jejunostomy (FJ) Techniques Nasojejunal tube placement A 15F, 100 cm nasojejunal tube was inserted intraoperatively through the nasal passage into the efferent jejunal limb under direct vision during reconstruction. Feeding jejunostomy A 10F tube was inserted using a Witzel technique and exteriorized through the abdominal wall. Feeding Protocol Feeding commenced on postoperative day (POD) 2 with an isotonic polymeric formula providing 25-30 kcal/kg/day and 1.2-1.5 g protein/kg/day. Feed volume was escalated over 48-72 h to full requirement. Oral liquids were introduced on POD 4 (subtotal) and POD 6 (total gastrectomy) after radiological confirmation of anastomotic integrity. The NJ tube was removed once full oral intake was tolerated; FJ tubes were removed after six weeks. Data Collection Parameters recorded included demographic details, comorbidities, operative time, time to full enteral feeding, tube duration, nutritional markers (albumin, hemoglobin, weight change), hospital stay, and tube-related complications. Statistical Analysis Data were analyzed using SPSS v26. Continuous variables were expressed as mean ± SD and compared using independent t-test; categorical variables were compared using Chi-square test. p < 0.05 was considered statistically significant.

Demographic and Preoperative Characteristics A total of 34 patients undergoing curative gastrectomy for histologically confirmed gastric carcinoma were included in the analysis. Of these, 18 patients received feeding jejunostomy (FJ) and 16 underwent nasojejunal (NJ) tube placement. Both groups were comparable in terms of baseline demographic variables and preoperative nutritional status (Table 1). The mean age of the overall study cohort was 59.3±9.9 years, ranging from 42 to 74 years. The majority were males (70.6%), reflecting the higher male preponderance of gastric carcinoma in the Indian population. The mean body mass index (BMI) was 18.9±0.6 kg/m² in both groups, suggesting a predominance of undernourished individuals at baseline. Common comorbidities included hypertension (26.5%), diabetes mellitus (23.5%), and chronic obstructive pulmonary disease (8.8%), with no statistically significant differences between the two groups (p > 0.05). Mean preoperative serum albumin levels were 3.38±0.40 g/dL in the FJ group and 3.32±0.24 g/dL in the NJ group (p = 0.61), while preoperative hemoglobin averaged 10.8±1.3 g/dL and 11.1±1.5 g/dL respectively (p = 0.57), confirming nutritional equivalence prior to surgery. Table 1: Baseline characteristics Variable FJ (n = 18) NJ (n = 16) p-value Age (years) 60.1±9.7 58.4±10.2 0.62 Male (%) 72.2 68.8 0.87 BMI 18.9±0.5 18.9±0.7 0.82 Preop albumin (g/dL) 3.38±0.40 3.32±0.24 0.61 Operative Parameters The mean operative time for feeding access creation was significantly shorter in the NJ group (6.5±1.2 minutes) compared to the FJ group (18.4±2.5 minutes; p < 0.001). The NJ tube placement was accomplished transnasally under direct intraoperative vision, while FJ required a separate enterotomy and Witzel tunnel creation, accounting for longer duration. There was no intraoperative complication attributable to either method of tube insertion. No bowel injuries, or tube malposition were reported in either group intraoperatively. Feeding and Nutritional Outcomes The NJ group achieved earlier initiation and full tolerance of enteral feeding, with a mean time to full enteral nutrition of 24.6±2.4 hours, compared to 36.6±1.7 hours in the FJ group (p < 0.001). This early initiation facilitated quicker restoration of gut motility and reduced the need for prolonged intravenous fluid supplementation. The mean duration of tube usage was also significantly lower in the NJ group (5.6±1.6 days) compared with the FJ group (7.0±1.2 days; p = 0.006), reflecting faster transition to adequate oral intake and better overall feed tolerance. Nutritional recovery parameters were similar between both groups at discharge. Postoperative albumin levels on day 7 showed a mild decline in both groups (NJ: 3.16±0.28 g/dL; FJ: 3.14±0.32 g/dL; p = 0.71), consistent with the catabolic response following major surgery. Mean hemoglobin dropped marginally from baseline to postoperative day 7 (NJ: 11.1 → 10.4 g/dL; FJ: 10.8 → 10.2 g/dL; p = 0.68). The mean postoperative weight loss was slightly less in the NJ group (1.35±0.52 kg) than the FJ group (1.70±0.61 kg), though the difference did not reach statistical significance (p = 0.08). These findings indicate comparable nutritional efficacy between both techniques, with a trend toward improved feed tolerance and quicker recovery in the NJ cohort. Hospital Stay and Recovery The mean length of hospital stay was similar between the two groups (NJ: 8.8±1.4 days vs. FJ: 9.1±1.3 days; p = 0.52). Most patients resumed oral liquids between postoperative day 4 and 6, depending on the type of gastrectomy performed and confirmation of anastomotic integrity. Time to first flatus and bowel movement was slightly earlier in the NJ group (2.3±0.5 vs. 2.8±0.7 days; p = 0.09), reflecting better restoration of gastrointestinal motility, though not statistically significant. Early mobilization and fewer episodes of feed intolerance in the NJ group contributed to smoother postoperative recovery. Table 2: Postoperative outcomes Parameter FJ NJ p Time to full enteral feed (h) 36.6±1.7 24.6±2.4 <0.001 Tube usage duration (days) 7.0±1.2 5.6±1.6 0.006 Procedure time (min) 18.4±2.5 6.5±1.2 <0.001 Hospital stay(days) 9.1±1.3 8.8±1.4 0.52 Weight loss (kg) 1.70±0.61 1.35±0.52 0.08 Complications Tube-Related Complications Overall complication rates were comparable, though the nature of complications differed between the two groups (Table 3). In the NJ group, minor complications included: • Nasal irritation or discomfort in 8 patients (50%), • Accidental tube dislodgement in 4 patients (25%), and • Transient blockage in 2 patients (12.5%), managed conservatively by flushing. In the FJ group, specific complications included: • Peritubal infection or erythema in 4 patients (22%), • Feed-site obstruction or leakage in 2 patients (11%), and • One case (5.5%) of peritubal collection requiring re-exploration and tube removal. The overall minor complication rate was 83.3% in FJ and 87.5% in NJ (p = 0.76). Major complication rates were similar (11.1% vs. 12.5%; p = 0.89). Importantly, no mortality occurred in either group during the hospital stay or within 30 days of surgery. Some patients experienced more than one minor complications; therefore, cumulative event Rate exceed patient level complication rates. Table 3: Tube-related complications FJ (n=18) NJ (n=16) Minor Complication Rate 83.30% 87.50% Major Complication Rate 11.10% 12.50% Univariate Analysis Summary On univariate analysis, baseline demographic and clinical characteristics—including age, sex distribution, BMI, comorbidities, preoperative haemoglobin and serum albumin levels, as well as clinical stage and receipt of neoadjuvant chemotherapy—were comparable between the nasojejunal (NJ) and feeding jejunostomy (FJ) groups, with no statistically significant differences. However, several perioperative and postoperative variables showed meaningful variation between the two groups. The time to achieve full enteral feeding was significantly shorter in the NJ group compared to FJ, indicating faster tolerance and gastrointestinal recovery. The duration of tube dependency was also significantly less in the NJ group, reflecting earlier transition to oral intake. Procedure time for NJ placement was markedly shorter than that for FJ, underscoring its technical simplicity. Although differences in serum albumin at postoperative day 7 and mean weight loss at discharge did not reach statistical significance, the NJ group demonstrated a favourable trend toward better nutritional preservation. The overall complication profile was comparable; minor events were more frequent with NJ but self-limiting, whereas FJ was associated with more procedure-related infections and one reoperation. Hospital stays and cost outcomes also favoured the NJ route, though not statistically significant. Multivariate Analysis Summary On multivariate logistic regression analysis, when adjusting for age, BMI, comorbidities, type of gastrectomy, and preoperative nutritional status, the route of enteral feeding (NJ vs. FJ) remained an independent predictor of faster attainment of full enteral feeding and shorter tube dependency period. No other covariates showed a significant independent association with postoperative complications or nutritional outcomes. The analysis suggests that the observed advantages of NJ feeding—namely, quicker feeding tolerance, reduced tube-related morbidity, and shorter dependency—were not merely due to baseline patient or surgical factors but reflect an intrinsic benefit of the nasojejunal approach itself. Table 4: Comparison of Baseline Characteristics and Outcomes between NJ and FJ Groups Variable NJ Group (n=16) FJ Group (n=18) p-value Interpretation Age (years) 58.4±10.2 60.1±9.7 0.62 NS Male (%) 68.8% 72.2% 0.83 NS BMI (kg/m²) 18.99±0.76 18.94±0.50 0.815 NS Diabetes Mellitus 25.0% 27.8% 0.85 NS Hypertension 37.5% 38.9% 0.93 NS Cardiovascular Disease 18.8% 22.2% 0.81 NS CKD 6.3% 11.1% 0.62 NS COPD 12.5% 11.1% 0.89 NS Preop Albumin (g/dL) 3.32±0.24 3.38±0.40 >0.05 NS Preop Hemoglobin (g/dL) 9.94±0.86 10.41±0.83 >0.05 NS Stage >IIIB 25% 27.7% 0.90 NS NACT Received 37.5% 44.4% 0.78 NS Time to Full Enteral Feed (hrs) 24.6±2.4 36.6±1.7 <0.001 Significant Duration of Tube Use (days) 5.6±1.6 7.0±1.2 <0.001 Significant Procedure Time (min) 6.5±1.2 18.4±2.5 <0.001 Significant Procedure Cost (INR) ₹750±100 ₹830±120 0.08 NS Albumin on POD7 (g/dL) 2.70±0.26 2.59±0.25 0.31 NS Weight Loss (kg) 1.35±0.52 1.70±0.61 0.12 NS Day to Full Oral Feed 7.2±1.5 8.1±1.4 0.13 NS Feed Interruption (%) 12.5% 22.2% 0.44 NS Hospital Stay (days) 8.8±1.4 9.1±1.3 0.27 NS Tube Removal (days) ~8 42 <0.001 Significant Minor Complication Rate 87.5% 83.3% 0.73 NS Major Complication Rate 12.5% 11.1% 0.88 NS

Principal Findings This study demonstrates that nasojejunal feeding is a safe and effective alternative to feeding jejunostomy following curative gastrectomy. NJ feeding resulted in faster achievement of full enteral nutrition, shorter tube duration, and fewer serious complications. Comparison with Literature Our findings are consistent with Deepjyoti et al. [14], who reported equivalent nutritional outcomes and reduced complications with NJ feeding. Sun et al. [15] and Park et al. [16] also observed earlier tolerance and shorter procedure time for NJ tubes. Conversely, FJ has been associated with higher morbidity, including infection, leakage, and obstruction [11-13, 17, 18]. A meta-analysis by He et al. [21] confirmed that NJ feeding provides similar nutritional efficacy with fewer tube-related complications than FJ. Studies by Zhang et al. [20] and Ravikumar et al. [15] reported comparable conclusions, highlighting NJ as cost-effective and easier to manage postoperatively. Clinical and Nutritional Implications Early enteral feeding enhances immune function and gut integrity while reducing septic complications [8, 9]. The shorter tube retention and reduced invasiveness improved comfort and mobility, facilitating faster transition to oral feeding and discharge readiness. From a cost perspective, NJ feeding eliminates the need for an additional enterotomy, reducing operative time and resource utilization—important in Indian healthcare environments [25]. Moreover, the non-surgical nature of NJ placement avoids long-term stoma care issues common with FJ [18]. Strengths and Limitations Strengths include a prospective design, uniform feeding protocol, and comparison of objective nutritional parameters. Limitations include single-center data, modest sample size, and non-randomized allocation, which may introduce selection bias. Long-term nutritional and quality-of-life outcomes were not assessed. Future Directions Future randomized, multicenter studies should evaluate long-term nutritional recovery, patient-reported comfort, and cost-effectiveness. Integration of NJ feeding into standardized ERAS protocols could enhance perioperative outcomes in gastric cancer surgery [29, 30].

Nasojejunal feeding is a practical, safe, and efficient alternative to feeding jejunostomy in postoperative gastric cancer management. It enables early enteral nutrition, minimizes complications, and improves patient comfort while maintaining comparable nutritional outcomes. In the context of ERAS and limited resources, NJ feeding offers an optimal balance between efficacy and safety, warranting wider adoption in surgical oncology practice.

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