Effect of a Personalized Enteral Nutrition Protocol on the Postoperative Nutritional Status in Patients Who Underwent Oral Cancer Surgery

Abstract

Differences in the implementation of the perioperative nutrition guidelines and pathways by caregivers lead to differences in enteral nutrition provided to the patients. This study investigated the effect of a personalized enteral nutrition protocol on the postoperative nutritional status of patients who underwent oral cancer surgery at Zhejiang Ningbo NO. 2 Hospital. Those who underwent surgery between July 2017 and October 2018 received routine enteral nutrition based on the Nutritional Risk Screening 2002 (routine group), while those between November 2018 and August 2021 received personalized enteral nutrition based on the Patient-Generated Subjective Global Assessment tool (personalized group). Seventy patients completed the study (routine group, n = 34; personalized group, n = 36). After surgery, the personalized group exhibited significantly greater improvements in serum albumin levels (P < 0.01) (on the 7th and 10th day) and hand grip strength (P < 0.01), higher self-care ability (P < 0.01), lower incidence of gastrointestinal reactions during enteral feeding (P < 0.05), and shorter hospital stay (P < 0.05) than the routine group. Therefore, a personalized enteral nutrition program might improve the postoperative nutritional status, shorten the hospital stay, and accelerate postoperative recovery in patients who underwent oral cancer surgery.

Introduction

Head and neck cancers arise from the mucous membranes of the mouth, lips, larynx, pharynx, cervical esophagus, nose, sinuses, skin, and salivary glands (1). Head and neck tumors rank first among cancers concerning the incidence and severity of weight loss (2). Among head and neck cancers, oral cancer is associated with tobacco use, alcohol consumption, and betel nut chewing (3). The incidence of oral cancer varies widely among geographic regions, but the mortality rate is high, emphasizing the need for early diagnosis and therapy (3). Surgery is the mainstay of definitive treatment for oral cancer. Preoperative and postoperative malnutrition, weight loss, and muscle mass loss are common in patients with oral cancer due to the hypermetabolic state, limitation of mouth opening, and impaired chewing and swallowing functions that occur after surgery (4). Malnutrition after surgery for oral cancer is an independent predictor of postoperative complications (5).

Enteral nutrition is a routine method for providing nutritional support after the radical resection of oral cancer. Published guidelines for using enteral nutrition after surgery in clinical practice are available (6), but guidelines specific to oral cancer are not available. An early study suggested that increased supervision could reduce weight loss after oral cancer surgery (7), but it did not specifically examine enteral nutrition.

There are wide differences and discrepancies in the implementation of evidence-based perioperative nutrition guidelines and pathways by caregivers, leading to differences in the level of enteral nutrition among patients (8, 9). The training of the caregivers, the involvement of nutritionists, and the design of individualized plans have improved the provision of enteral nutrition to critically ill patients (10). It is acknowledged that further research into patient preferences and interdisciplinary collaborations will help promote consistent, evidence-based, and patient-centered enteral nutrition practice (11). A recent retrospective study showed that the referral of patients to a multidisciplinary team for feeding issues reduced the length of hospital stay (LOHS) (12), but the nutritional status indicators were not investigated. In the present study, a multidisciplinary nutrition management team developed a personalized enteral nutrition protocol based on the Patient-Generated Subjective Global Assessment (PG-SGA) tool (13) and nutritional guidelines (14), with the specific calculation of target energy values, target protein values, nutrient solution concentration changes, weekly nutrient target values, vitamin intake, and using an intermittent infusion pump.

This study investigated whether implementing the personalized enteral nutrition protocol would improve the postoperative nutritional status and shorten the LOHS of patients undergoing surgery for oral cancer.

Methods

Study Design and Participants

This study (physician-preference trial) included patients who underwent surgery for oral cancer at the Department of Stomatology in Zhejiang Ningbo NO.2 Hospital and Ningbo Institute of Life and Health Industry between July 2017 and August 2021. The inclusion criteria were (1) a diagnosis of oral cancer confirmed preoperatively by pathological biopsy, (2) no preoperative radiotherapy or chemotherapy, (3) preoperative Barthel score ≥ 75 points, and (4) the patient underwent extended tumor resection, repair with skin flap transplantation, and tracheotomy. The exclusion criteria were (1) impaired limb movement due to limb fracture or other limb disorder, (2) impaired cognitive function or inability to cooperate with the study protocol, (3) severe cardiovascular disease, organ insufficiency, or diabetes mellitus, or (4) severe gastrointestinal dysfunction such as severe diarrhea, digestive tract obstruction, or gastrointestinal bleeding.

This study was approved by the ethics committee of Zhejiang Ningbo NO.2 Hospital and Ningbo Institute of Life and Health Industry (approval number: PJ-NBEY-KY-2019-090-01). All patients provided informed written consent and voluntarily participated in the study.

Intervention

A multidisciplinary nutrition management team comprising medical, nursing, and nutritionist teams was established in the Department of Stomatology. The two medical teams included a team leader with the title of deputy chief physician or higher, an attending physician, and two resident physicians. Each nursing team included a team leader who held the title of chief nurse and had more than 5 years of clinical nursing experience in the stomatology department, a head nurse who held the title of deputy chief nurse, and three nurses with at least 2 years of clinical nursing experience in the stomatology department. The members of the nutritionist team all had bachelor’s degrees and included the director of the nutrition department, who held the title of deputy chief physician and nutritionist. There was a clear division of labor among the three teams. The medical team was responsible for disease diagnosis and management, therapeutic guidance provision, and vital indicators monitoring. The nutritionist team attended every 1–3 day and was responsible for evaluating the patient’s nutritional status and gastrointestinal tolerance. The nursing teams were responsible for administering enteral nutrition, observing and nursing the patient, and monitoring the overall quality of care. The management team members provided feedback to each other, promoted effective communication and discussion through common ward rounds, group meetings, work groups, or telephone conversations, and dynamically adjusted the intake of nutrient solutions.

The patients who underwent surgery for oral cancer between July 2017 and October 2018 received routine enteral nutrition (routine group), while those who underwent surgery for oral cancer between November 2018 and August 2021 received personalized enteral nutrition (personalized group). Although doctors, nurses, and dietitians jointly managed enteral nutrition for patients in both routine group and personalized group, the Nutritional Risk Screening 2002 (NRS2002) instrument was used for nutritional assessment and recommendation in the routine group, while the PG-SGA tool and NRS2002 were used for the personalized group. Although the nutrition intake of the routine group was implemented according to the enteral nutrition standards of surgical nursing combined with the gastrointestinal tolerance of patients, there was no target value for the specific nutrition plan. In the personalized group, individualized nutrition plans were developed, with the specific calculation of target energy values, target protein values, nutrient solution concentration changes, weekly nutrient target values, vitamin intake, etc. In addition, in the routine group, the nasal feeding perfusion apparatus was used, and the concentration and intake of nutrient solution were not specified and refined. In the personalized group, an intermittent infusion pump was used to change the nutrient concentration gradient, prolong the feeding time, and increase the amount of each feeding. The intervention differences between the two groups are detailed below.

Routine Enteral Nutrition

The dietitian provided assessment and recommendations for nutritional support based on the patient’s age, body mass index, comorbidities, dietary review, food allergy history, postoperative clinical condition, gastrointestinal tolerance, and laboratory test results. The nurses performed the nutritional screening of the patients after surgery using the NRS2002 instrument. If the NRS2002 score was three or more, the patient’s nutritional status was evaluated by a doctor, and input from a dietitian was requested if necessary. An indwelling nasogastric tube was placed on the day after surgery for oral cancer, and mixed enteral and parenteral nutritional support was given. The full concentration of 25% dietary homogenate (Supplementary materials) prepared by the nutrition department was selected for nasogastric enteral nutrition. The enteral nutrient solution was slowly infused into the nasogastric tube over 10–20 mins, 6–8 times/day (15). The initial volume of nutrient solution administered was 50–100 ml per meal, but it was increased to a maximum of 300 ml per meal according to the tolerance of the gastrointestinal tract. The patients were able to request enteral nutrition according to their needs. The daily intake of enteral food was recorded and checked by the nurses. If the daily intake was deemed insufficient, the patient was asked to increase the amount of dietary homogenate to an appropriate level, provided it was tolerated. Blood glucose, serum electrolytes, and liver and kidney functions were monitored, and the treatment plan was adjusted if abnormalities were detected. Enteral nutrition was provided for 10–20 day after surgery, after which the nasogastric tube was removed, and the patient started eating by mouth.

Personalized Enteral Nutrition

The nutritional assessment was conducted according to the PG-SGA tool and NRS2002. The nutritional status of the patients was classified into good nutrition (A), suspected or moderate malnutrition (B), and severe malnutrition (C). The specific PG-SGA scores were not collected. A detailed assessment of the nutritional status of each patient in the personalized group was obtained through the evaluation of the patient’s height, weight, upper-arm circumference, muscle mass, degree of orthostatic edema, ascites, weight loss in the past 6 months, dietary intake, gastrointestinal symptoms, physical strength, lesions, amount of subcutaneous fat, food allergy history, laboratory test results, clinical condition, underlying diseases, and metabolic status after surgery. The dietitians performed repeated evaluations every week to assess for complications, risks of aspiration, and gastrointestinal reactions during enteral feeding. Based on the nutritional assessment and the recommendations of nutritional guidelines (15), individualized values for the energy target, protein target, initial concentration of the nutrient solution, recommended volume of nutrient solution per meal, and the number of meals per day were determined for each patient. Recommendations were made for monitoring liver and kidney function, serum electrolytes, and blood glucose. Targets achievable within 1 week were set for energy intake, laboratory parameters, and change in body weight. The clinicians and nurses monitored the patients’ implementation of the nutritional prescriptions. The nutritionist calculated the patient’s individualized target energy value and target protein value according to the following formulae (15): Ideal body mass = (height-105)kg; daily target energy value = ideal body mass × (25–30) kcal/kg/dayTarget protein requirement = ideal body weight × (1.2–2.0) g/kg/day; actual daily energy intake = total daily intake of nutrient solution × (actual fractional concentration/0.25)Actual daily intake of protein = total daily intake of nutrient solution × actual fractional concentration × 0.2.

The specific values for each patient were recalculated every week according to the results of the nutritional evaluation and the metabolic characteristics of the patient after surgery (16). According to the nutrition plan, the nurses implemented enteral nutrition using an intermittent infusion pump, gradually increasing the concentration and amount of enteral nutrition solution and feeding times based on gastrointestinal tolerance. (a) On the first day after surgery, 200 ml of 10% nutrient solution (100 ml of nutrient solution contained 40 kcal of calories) was infused over 60–90 mins, 3–5 times/day (total volume administered, 600–1000 ml/day; calorie intake, 240–400 kcal/day). Two days postoperatively, depending on gastrointestinal tolerance, the concentration and volume of the nutrient solution were adjusted to 15% and 200–300 ml per administration (infused over 60–90 mins,), respectively, about 5 times/day (total volume, 1000–1500 ml/day; calorie intake, 600–900 kcal/day). (c) 3–4 day postoperatively, an adjustment was made so that 300–500 ml of 25% nutrient solution was infused (over 60–90 mins,) 5–6 times/day (total volume, 1500–2400 ml/day; calorie intake, 1500–2400 kcal/day). (d) If the patient has gastrointestinal intolerance, the increase of concentration and intake was delayed, and the achievable goal for the first week was to reach an energy intake that exceeded 75% of the target. The doctors, nurses, and nutritionists regularly monitored the key indicators of nutritional status and dynamically adjusted the individualized nutritional plan as required. The indicators of nutritional status included body weight, serum albumin concentration, blood glucose level, hand grip strength, and upper arm circumference.

Outcomes

The primary outcomes were body weight, serum albumin levels, and hand grip strength (indicators of nutritional status), evaluated on the day before the operation and day 7 and 10 after surgery. Bodyweight was measured with the patient wearing only a gown after an overnight fast using the same calibrated scales. Serum albumin was measured using a blood sample after an overnight fast (the sample was also used for the other laboratory tests); the reference range was 40–55 g/L. Grip strength (an indicator of upper limb muscle strength and nutritional status) was measured between 9:00 and 10:00 in the morning with the patient standing. The grip strength of each hand was measured three times using a hydraulic grip dynamometer (Jamar Plus EN120604), and the average value was used for the analyses.

The secondary outcomes included self-care ability, the incidence of gastrointestinal reactions, and LOHS. Self-care ability (used as a measure of postoperative recovery) was evaluated using the Barthel index score (17), which assesses 10 items: feeding, personal toileting, bathing, dressing/undressing, getting on/off a toilet, controlling the bladder, controlling bowel, moving from wheelchair to bed and returning, walking on a level surface, and ascending/descending stairs. The maximum score is 100 points, with 61–95 points indicating mild dependence, 41–60 points indicating moderate dependence, and ≤40 points indicating severe dependence. Any gastrointestinal reactions during enteral nutrition, including symptoms of abdominal distention, vomiting, diarrhea, abdominal fullness or swelling, increased bowel movements, and thin stools, were recorded. LOHS was calculated as the time from surgery to discharge from the hospital.

Statistical Analysis

Although the sample size was not calculated before conducting this study, the post hoc power for the primary outcomes was analyzed by Gpower 3.1 software, and the result was 0.904.

SPSS 26.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. Continuous data conforming to the normal distribution were expressed as means ± standard deviations (SD) and compared between groups using the t-test for independent samples or repeated measures analysis of variance (ANOVA). Continuous data not conforming to the normal distribution were described as median (interquartile range) and compared between groups using the Scheirer–Ray–Hare test. Categorical data were expressed as frequency and percentage and were analyzed using the chi-squared test. A P-value < 0.05 was considered statistically significant.

Results

Seventy-eight patients were initially included, but 70 completed the study. The routine group included 36 patients (23 males, 67.65%) aged 61.50 ± 11.55 years old, and the personalized group consisted of 34 patients (28 males, 77.78%) aged 65.83 ± 8.67 years old. There were no significant differences between the two groups regarding sex, age, preoperative body mass index, preoperative nutritional screening score, tumor location, clinical stage, operative time, intraoperative blood loss, C-reactive protein levels, or white blood cell counts (Table 1). The patients did not intake foods orally during enteral nutrition.

Table 1. Comparisons of preoperative and intraoperative characteristics between patients in the two groups.

Variables	Personalized group (n = 36)	Routine group (n = 34)	P group value	P time value	P group × time value
Gender, n (%)			0.341	–	–
Male	28 (77.78%)	23 (67.65%)
Female	8 (22.22%)	11 (32.35%)
Age (years), mean ± SD	65.83 ± 8.67	61.50 ± 11.55	0.079	–	–
Body mass index (kg/m^2), mean ± SD	22.91 ± 3.15	23.25 ± 2.59	0.627	–	–
Nutritional screening score (points), median (IQR)	1 (1.00–1.25)	1 (1.00–1.00)	0.543	–	–
Operative time (minutes), mean ± SD	282.61 ± 89.92	294.56 ± 134.59	0.469	–	–
Intraoperative blood loss (mL), median (IQR)	275 (150,300)	250 (150, 362.5)	0.871	–	–
Clinical stage, n (%)			0.642	–	–
I	12 (33.33%)	15 (44.12%)
II	12 (33.33%)	10 (29.41%)
III	12 (33.33%)	9 (26.47%)
Tumor lesion location, n (%)			0.252	–	–
Tongue	9 (25.00%)	17 (50.00%)
Floor of mouth	11 (30.56%)	8 (23.53%)
Gums	3 (8.33%)	4 (11.76%)
Cheek	4 (4.11%)	2 (5.88%)
Palate	5 (13.89%)	2 (5.88%)
Jawbone	4 (11.11%)	1 (2.94%)
White blood cell count(*10^9/L), mean ± SD
1 day before surgery	6.41 ± 2.45	6.01 ± 1.70	0.746	<0.010	0.403
7 day after surgery	8.68 ± 1.61	9.23 ± 2.98
10 day after surgery	7.68 ± 1.37	7.81 ± 2.02
C reactive protein (g/L), mean ± SD
1 day before surgery	5.87 ± 13.60	6.14 ± 9.47	0.196	<0.010	0.612
7 day after surgery	38.11 ± 27.00	33.15 ± 25.37
10 day after surgery	21.09 ± 15.43	15.86 ± 13.02

Abbreviations: IQR: interquartile range; SD: standard deviation.

Serum albumin levels, dominant hand grip strength, and non-dominant hand grip strength were lower after than before the operation in both groups (Table 2). Notably, after surgery, the personalized group exhibited greater improvements in serum albumin levels (P < 0.01) (on the 7^th and 10th day, P < 0.05), dominant hand grip strength (P < 0.01), and non-dominant hand grip strength (P < 0.01) than the routine group (Table 2). Bodyweight decreased after surgery in both groups but was not significantly different between groups on day 7 and 10 after the operation (P > 0.05) (Table 2).

Table 2. Primary outcomes (nutritional status).

Outcome	Routine group (n = 34)	Personalized group (n = 36)	F group value/P-value	F time value/P-value	F group × time value/P-value
Serum albumin level (g/L), mean ± SD
1 day before surgery	42.72 ± 4.11	41.78 ± 3.34	−2.210/0.030	127.020/<0.010	12.810/<0.010
7 day after surgery*	33.51 ± 3.73	35.59 ± 3.36
10 day after surgery*	34.32 ± 3.22	37.66 ± 2.84
Dominant hand grip strength (kg), mean ± SD
1 day before surgery	33.80 ± 8.34	31.89 ± 8.05	−0.712/0.480	60.290/<0.010	17.660/<0.010
7 day after surgery	27.66 ± 7.09	29.73 ± 8.08
10 day after surgery	28.81 ± 7.38	30.99 ± 7.84
Non-dominant hand grip strength (kg), mean ± SD
1 day before surgery	30.03 ± 7.54	29.59 ± 6.94	−1.030/0.310	53.780/<0.010	6.230/<0.010
7 day after surgery	25.47 ± 6.48	27.11 ± 6.86
10 day after surgery	26.79 ± 6.66	28.60 ± 7.14
Bodyweight (kg), median (IQR)
1 day before surgery	64.65 (59.25–70.50)	62.25 (52.13–70.00)	0.006/0.936	2.876/0.237	1.236/0.538
7 day after surgery	60.90 (55.75–68.00)	61.50 (51.13–68.88)
10 day after surgery	60.00 (54.75–66.250	61.75(51.25–68.00)

Abbreviations: IQR: interquartile range; SD: standard deviation.

*P < 0.05 (routine group vs. personalized group).

Self-care ability (as measured by the Barthel index score) decreased after surgery in both groups but was higher in the personalized group (P < 0.01) than in the routine group (on the 7th and 10th day, P < 0.05). The incidence of gastrointestinal reactions during enteral support was significantly lower in the personalized group than in the routine group (P < 0.05). In addition, LOHS was significantly shorter in the personalized group than in the routine group (P < 0.05) (Table 3).

Table 3. Secondary outcomes.

Outcome	Routine group (n = 34)	Personalized group (n = 36)	F group value/P-value	F time value/P-value	F group × time value/P-value
Barthel score (self-care ability), median (IQR)
1 day before surgery	100.00 (100.00–100.00)	100.00 (100.00–100.00)	9.603/<0.010	106.980/<0.010	4.242/0.120
7 day after surgery*	77.50 (58.75–90.00)	90.00 (80.00–93.75)
10 day after surgery*	100.00 (85.00–100.00)	100.00 (100.00–100.00)
Incidence of gastrointestinal reactions, n (%)
bloating	5 (14.70%)	1 (2.78%)	5.137/0.032	–	–
Vomit	2 (5.88%)	0 (0%)
diarrhea	3 (8.82%)	2 (5.56%)
No reaction	24 (70.59%)	33 (91.67%)
LOHS (days), median (IQR)	22.00 (16.75–29.00)	18 (14.50–21.75)	−2.175/0.030	–	–

Abbreviations: IQR: interquartile range; LOHS: length of hospital stay; SD: standard deviation.

*P < 0.05 (routine group vs. personalized group).

Discussion

This study suggested that the use of a personalized enteral nutrition program resulted in more rapid improvements in postoperative serum albumin concentration and hand grip strength, faster recovery of self-care ability after surgery, lower incidence of gastrointestinal reactions, and shorter LOHS, indicating that individualized and easy-to-implement personalized enteral nutrition protocol might improve the nutritional status and accelerate the recovery of patients after surgery for oral cancer.

It is widely acknowledged that the implementation of enteral nutrition varies among patients and hence be suboptimal in many cases (8, 9). Previous research concluded that caregiver training programs, input from nutritionists, and individualized plans could help optimize enteral nutrition in patients who were critically ill or had cancer (10, 18–21). Huang et al. (10) surveyed 808 intensive care unit nurses and observed that having EN-related training, the full-time presence of a nutritionist in the ICU, higher hospital level, having specific protocols for enteral feeding, and higher nurse position were influencing enteral feeding of the patients. In the study by Bonomo et al. (18), a clinical practice specialist, staff registered nurse, and registered dietitian led the design and implementation of a personalized enteral nutrition protocol for intensive care patients, but their measure of success was based on the actual delivery of the prescribed volume. Lee et al. (20) also examined a multidisciplinary approach in intensive care patients and showed that the multidisciplinary care improved the percentage goal kCal and protein and led to a shorter LOHS. Kim et al. (21) developed a multidisciplinary protocol that led to the earlier implementation of enteral nutrition and more patients achieving their energy goals. Zhang et al. (19) performed an audit of nursing quality in 60 patients with gastric cancer and 10 nurses before and after implementing a best practice program to prevent underfeeding during enteral nutrition, showing the program’s success. The findings of the present study are in good agreement with these previous reports and highlight the potential benefits of using individualized enteral nutrition programs designed and implemented by a multidisciplinary team of clinicians, nurses, and nutritionists. While individualized nutritional prescriptions rely on formulae to calculate target energy values and protein requirements, as recommended by the guidelines, assessments of nutritional status need to be repeated weekly to enable the dynamic optimization of the strategies for energy and protein intake. Especially, patients with oral cancer often have feeding issues and often present malnutrition before surgery. Therefore, they represent a special category of surgical patients (4).

Providing optimal nutritional support after surgery requires the consideration of the energy/nutrient requirements and the unique needs, values, preferences, and psychosocial status of each individual patient. All these factors can be evaluated by a nutritionist through repeated assessments of the patient’s clinical and nutritional status and establishing clear communication with the patient to ensure that they fully understand the reasons for enteral nutrition and comply with therapy. A recent survey of patients with head and neck cancer identified several psychosocial issues that affected the acceptance of enteral nutrition by a patient, emphasizing the importance of adequate psychological assessment and counseling to ensure that the patient accepts and complies with the enteral nutrition program (22). Patient autonomy and quality of life should be considered when decisions are made regarding medical nutrition therapy (23). A patient-centered nutritional assessment reduces decision-making conflict, improves the relationship between the healthcare providers and the patient, and can enhance the patient’s quality of life. The present study used the NRS2002 tool for nutritional screening and the PG-SGA instrument for nutritional assessment. It has been reported that the self-completion of the PG-SGA can increase the patient’s awareness of malnutrition risk and improve the ability of the patient and their caregivers to prevent and treat malnutrition, facilitating the implementation of timely intervention for malnutrition and optimizing treatment adherence (24).

A lack of energy is associated with various complications, and malnutrition is an independent risk factor for poorer clinical outcomes after surgery (25). Moreover, malnutrition increases healthcare costs by prolonging LOHS and increasing the readmission rate (26, 27). Energy requirements can be determined by indirect calorimetry or, if not available, calculated using a formula. In this study, a personalized target energy value was calculated with a formula after a comprehensive patient evaluation. Furthermore, the patients were assessed at regular intervals to allow for the dynamic optimization of the enteral nutrition protocol. Successful enteral nutrition guided by 24-h target energy values can increase nutrient delivery and reduce the incidence of nosocomial infections (28, 29). Nevertheless, controversies remain regarding the optimal energy intake for critically ill patients, with some studies suggesting that a higher intake does not lead to higher survival rates (30). In this study, the patients in both groups lost weight. Postoperative weight loss is inevitable, given that patients have a high metabolic rate and are in a state of stress after major surgery. Although bodyweight on postoperative day 7 and 10 did not differ significantly between the personalized and routine groups, it was notable that the amount of postoperative weight loss was numerically smaller in the personalized group than in the routine group at both these time points. Given the small sample size of this study, it is possible that our study was underpowered to detect a real significant difference in body weight between the two groups.

Patients who undergo resection of oral cancer experience surgical trauma that leads to a hypermetabolic catabolic state and hence reductions in body weight, muscle mass, and grip strength during hospitalization (4). Critically ill patients with low protein reserves (low muscle mass) are at the highest risk of malnutrition and may benefit more from early nutritional intervention with protein supplementation (31). Studies have shown that patients who achieve both protein and energy goals have a lower mortality rate than those who achieve energy goals alone (32). The protein requirements of critically ill patients are higher than their energy requirements. Since the protein content in the conventional enteral nutrition preparation could not fully meet the body’s needs after surgery, the nutrient solution used in the present study was supplemented with whey protein (only in the personalized group). A supplementation of whey protein has been shown to reduce the risk of postoperative complications in patients with head and neck cancer (33). Furthermore, an adequate nutrient intake, especially protein, is important for the prevention and treatment of malnutrition during hospitalization and can reduce the risks of complications and longer LOHS (34). The present study suggests that supplementation with whey protein powder according to gastrointestinal tolerance could help maintain an adequate supply of protein to the patients in the personalized group. This proposal is supported by the findings that the patients in the personalized group exhibited a faster recovery of hand grip strength and self-care ability and had a shorter LOHS than those in the routine group. Since vitamins can improve the prognosis of patients after major surgery (35), the study protocol also included the addition of water-soluble vitamin components to the enteral nutrition preparation in line with guideline recommendations.

The optimal mode of feeding for enteral nutrition remains debated. Although certain guidelines recommend continuous infusion rather than intermittent enteral nutrition, some experts believe that this is inconsistent with gastrointestinal physiology, and the results of systematic reviews are equivocal (36). In this study, the physiological and psychological needs of the patients undergoing surgery for oral cancer were fully considered. Compared with continuous feeding, intermittent feeding enables patients to gain more time for activities and get out of bed early, which aligns with the concept of rapid postoperative recovery (37). In this study, the enteral nutrient solution was administered to the patients in the personalized group using a pump rather than a syringe, which extended the feeding time from 10 to 20 mins, (syringe feeding) to about 1 h. In addition, the amount of nutrient solution administered was gradually increased from an initial value of 100–300 ml each time to 200–500 ml. We believe that these improvements likely contributed to a reduction in the symptoms of gastrointestinal intolerance (such as abdominal distension, diarrhea, vomiting, regurgitation, and aspiration) caused by excessive intake of the enteral preparation while allowing an increase in the total amount of food administered. Indeed, the results showed that gastrointestinal complications were lower in the personalized group than in the routine group. Therefore, gradually increasing the volume of food administered according to gastrointestinal tolerance coupled with slower infusion using a pump rather than a syringe might help optimize enteral nutrition.

There were several limitations to this study. It was a single-center study with a small sample size, and the generalizability of the results remains unknown. It was not a randomized controlled trial, and the patients in the two groups were recruited at different periods (i.e. before and after the implementation of the multidisciplinary management). Since a hospital is an ever-changing environment, other changes in management protocols in the hospital between the two periods or other unknown factors might have influenced the results. The roles of other nutritional interventions, such as preoperative nutritional support, parenteral nutrition, and self-feeding, were not assessed since the personalized protocol only covered enteral nutrition. In addition, the clinical nutrition status (such as the PG-SGA scale) and the actual intake of the feeding after receiving the intervention were not considered in the present study, which might not be a careful consideration. Nevertheless, the authors focused on the serum albumin level, hand grip strength, and body weight of the patients, which could indicate the nutritional status of patients in other aspects. Research will be carried out in the future to explore that. Finally, a follow-up to evaluate the long-term outcomes was not performed. Therefore, the findings will need to be verified by a large-scale, multicenter study that would monitor a wider range of nutritional indicators (including muscle mass) and evaluate outcomes over a longer follow-up period.

In conclusion, implementing the individualized and easy-to-implement personalized enteral nutrition protocol might improve the nutritional status and accelerate patients’ recovery after oral cancer surgery. This protocol might be worth promoting in the postoperative management of oral cancer patients undergoing surgery.

Author Contribution

Qing Chen and Chunbo Ding equally contributed to the conception and design of the research; Bin Xu contributed to the design of the research; Feng Zhang contributed to the acquisition and analysis of the data; Chunbo Ding and Huiqin Zhang contributed to the interpretation of the data; and Qing Chen and Chunbo Ding drafted the manuscript. All authors critically revised the manuscript, agreed to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.

Ethical Approval

This study was approved by the ethics committee of Zhejiang Ningbo NO.2 Hospital and Ningbo Institute of Life and Health Industry (Ethics number: PJ-NBEY-KY-2019-090-01). All patients provided informed written consent and voluntarily participated in the study.

Disclosure Statement

The authors declare there are no competing interests to declare.

Data Availability Statement

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.

Additional information

Funding

This work was supported by the Zhejiang Province Medical and Health Science and Technology Program (Project Number:2019KY586), Funded by the Project of NINGBO Leading Medical & Health Discipline (Project Number:2022-F20).