Published online Sep 27, 2026. doi: 10.4240/wjgs.120780
Revised: May 24, 2026
Accepted: June 24, 2026
Published online: September 27, 2026
Processing time: 157 Days and 23.5 Hours
Gastric cancer is among the most common digestive tract malignancies world
To analyze independent risk factors of delayed gastrointestinal recovery in pati
A total of 293 patients who underwent radical gastrectomy in our hospital between January 2021 and July 2025 were retrospectively analyzed. On the basis of postoperative gastrointestinal recovery status, patients were divided into a normal group (218 cases) and a delayed group (75 cases). General information, preoperative lab indicators, tumor-related data, and surgery-related data were collected. Independent risk factors were screened by univariate and multivariate logistic regression analysis. A Nomogram prediction model was established according to multivariate analysis results. Discrimination, calibration and clinical value of the models were assessed using receiver operating characteristic (ROC) curves, Hosmer-Lemeshow goodness-of-fit test, calibration curves and decision curve analysis (DCA). Validation: Internal validation was performed by the Bootstrap method (1000 repeated samplers).
Among 293 patients, delayed gastrointestinal recovery occurred in 75 cases (25.6%). Multivariate logistic regression analysis revealed that age ≥ 65 years [odds ratio (OR) = 2.18, 95%CI: 1.14-4.17, P = 0.018], underweight (OR = 2.87, 95%CI: 1.38-5.97, P = 0.005), American Society of Anesthesiologists (ASA) grade III (OR = 2.42, 95%CI: 1.28-4.58, P = 0.007), preoperative hypoalbuminemia (OR = 2.53, 95%CI: 1.31-4.89, P = 0.006), tumour, node, and metastasis (TNM) stage III (OR = 2.15, 95%CI: 1.14-4.06, P = 0.018) and total gastrectomy (OR = 3.28, 95%CI: 1.65-6.52, P = 0.001) were independent risk factors for delayed gastrointestinal recovery. The Nomogram prediction model constructed based on the above 6 factors had an area under the ROC curve (AUC) of 0.802 (95%CI: 0.747-0.857); the Hosmer-Lemeshow test yielded χ2 = 6.823 (P = 0.556); DCA showed that the model had net benefit within a threshold probability range of 0.10-0.75; the corrected C-index after Bootstrap internal validation was 0.793 (95%CI: 0.736-0.850).
Age ≥ 65 years, underweight, ASA grade III, preoperative hypoalbuminemia, TNM stage III and total gastrectomy are independent risk factors for delayed gastrointestinal recovery after radical gastrectomy. The nomogram prediction model established in this study has good discriminatory and calibration ability and clinical usefulness, that can preoperatively identify high-risk patients, which provides a scientific basis for formulating individualized perioperative management strategies.
Core Tip: Gastrointestinal recovery is crucial after radical gastrectomy; however, delayed gastrointestinal recovery is a common complication following surgery, affecting postoperative outcomes. Age ≥ 65 years, underweight status, American Society of Anesthesiologists (ASA) grade III, preoperative hypoalbuminemia, tumour, node, and metastasis (TNM) stage III and total gastrectomy were all identified as independent risk factors in this retrospective cohort study. After Bootstrap validation, a Nomogram including these variables showed good discrimination, calibration and clinical utility. Five of the six predictors (age, body mass index, ASA grade, serum albumin, and TNM stage) are identifiable preoperatively within a standard diagnostic workup, while total gastrectomy is determined intraoperatively. This accessibility enables early preoperative risk stratification and guides individualised perioperative management. Application of this approach may help to optimize nutritional intervention, ameliorate surgical planning and contribute to improvement in enhanced recovery after surgery inductees allowing for an expedited return of gastrointestinal activity along with prognostically favorable outcomes for the patient.
- Citation: Wang CY, He HY, Li SS, Zhu QQ. Risk factors and nomogram for predicting delayed gastrointestinal recovery after radical gastrectomy. World J Gastrointest Surg 2026; 18(9): 120780
- URL: https://www.wjgnet.com/1948-9366/full/v18/i9/120780.htm
- DOI: https://dx.doi.org/10.4240/wjgs.120780
Gastric cancer represents one of the most common malignant tumors originating from the digestive tract worldwide with incidence and mortality rates being among the highest for all malignancies[1]. Surgical resection is still the best choice for curative treatment of gastric cancer, but delayed postoperative gastrointestinal recovery is an alarming complication that influences patient recovery and prognosis[2]. Prolonged gastrointestinal recovery can result in prolonged hospitalization, increased medical expenses, increased risk of postoperative complications and even delay of adjuvant therapy, which will seriously affect the quality of life and long-term survival[3]. The incidence of delayed gastrointestinal recovery after radical gastrectomy has been reported to be 15% to 35%, and its occurrence is affected by various factors related to the patient, tumor, surgical approach, and perioperative management[4].
The newest addition to this is the identification of high-risk patients for delayed gastrointestinal recovery and the implementation of specific measures to ensure rapid recovery (enhanced recovery after surgery)[5]. Recent domestic and international studies on the factors that delay gastrointestinal recovery after gastric cancer surgery are mostly single or partial factor analysis without systematic, multidimensional comprehensive evaluation and there are no mature prediction models which can be justified for clinical use[6]. Specifically, existing models have been limited by narrow variable selection focusing on either surgical or nutritional factors alone, small single-institution cohorts without external validation, or inclusion of postoperative variables that preclude true preoperative risk stratification. Thus, making a scientific and accurate prediction model may assist clinicians to identify high-risk patients preoperatively and formulate tailored perioperative management methods, thus reducing delayed gastrointestinal recovery[7] which contributes to fast recovery of patients. The study is a retrospective analysis of clinical data from radical gastrectomy patients, aimed at systematically identifying independent risk factors for delayed gastrointestinal recovery and establishing the Nomogram prediction model to guide clinical decision-making.
The clinical data of patients who underwent radical gastrectomy in our hospital from January 2021 to July 2025 were retr
Inclusion criteria: (1) Pathologically diagnosed with gastric cancer; (2) Patients underwent radical gastrectomy (including distal subtotal gastrectomy, proximal subtotal gastrectomy or total gastrectomy); (3) Age ≥ 18 years old; and (4) Complete clinical data.
Exclusion criteria: (1) Preoperative intestinal obstruction or gastrointestinal perforation; (2) Patients who underwent emergency surgery; (3) The intraoperative discovery of distant metastasis that required palliative surgery; (4) Death within 30 days after operations due to non-gastrointestinal causes; and (5) Loss of core clinical data, missing > 5% of data. Finally, 293 patients were included based on inclusion and exclusion criteria. This study was approved by the ethics committee of our hospital, and informed consent was waived.
Based on the relevant domestic and international literature and the “Chinese Expert Consensus on Perioperative Management of Enhanced Recovery After Surgery (2021 Edition)”[8,9], delayed recovery of gastrointestinal function was defined as that at least 2 of the following indicators occurred within 7 days after surgery: (1) First flatus time > 72 hours; (2) First bowel movement time > 96 hours; (3) Analgesic nausea and vomiting requiring nasogastric tube access or placement > 48 hours; (4) Fast depletion for not being able to tolerate oral intake > 5 days, fast emptying required; and/or (5) Imaging examination showed intestinal paralysis or obstruction (imaging modalities included abdominal plain radiography and/or computed tomography, performed at the attending surgeon’s discretion; no standardized imaging protocol was mandated). Patients were classified based on these criteria into a normal gastrointestinal recovery group and delayed gastrointestinal recovery group.
Patient data were obtained from the hospital electronic medical record system.
General information: Gender, age, body mass index [body mass index (BMI), classified according to World Health Organization Asia-Pacific standards: < 18.5 kg/m2 as underweight; 18.5-22.9 kg/m2 as normal; 23.0-24.9 kg/m2 as overweight; and ≥ 25.0 kg/m2 as obese], smoking history (defined as cumulative smoking of ≥ 100 cigarettes and having smoked single cigarette more than once daily in the past year), history of alcohol consumption (defined by drinking frequency ≥ 2 times/week and amount exceeding 40 g pure alcohol/occasion in the last one year period), comorbidities [hypertension, diabetes mellitus (DM), coronary heart disease, chronic obstructive pulmonary disease (COPD), cirrhosis], previous abdominal surgery history, American Society of Anesthesiologists (ASA) classification were also collected for group comparisons across baseline demographic variables and clinical characteristics.
Preoperative laboratory indicators: Hemoglobin (Hb, g/L; anemia if Hb < 120 g/L in males, < 110 g/L in females), albumin (Alb, g/L; hypoalbuminemia if Alb < 35 g/L), serum sodium (mmol/L; 135-145 mmol/L suggested as normal range) serum potassium (mmol/L; 3.5-5.5 mmol/L suggested as normal range), fasting blood glucose(mmol/L; 3.9-6.1 mmol/L suggested as normality), tumor markers [carcinoembryonic antigen (CEA, ng/mL; CEA normal value: < 5 ng/mL); carbohydrate antigen 19-9 (CA19-9, U/mL; CA199 normal value: < 37 U/mL)]. For all indicators, test results were used from the most recent 3 days preoperatively and closest to the time of surgery.
Tumor-related data: Tumor location (upper gastric, middle gastric, lower gastric, diffuse type), maximum tumor diameter (cm), pathological type (Lauren classification: Intestinal, diffuse/mixed type), degree of differentiation (well-differentiated/moderately differentiated/poorly differentiated/undifferentiated), invasion depth of the primary tumor (T stage), lymph node metastases (N stage) and tumour, node, and metastasis (TNM) staging were considered according to the 8th edition of American Joint Committee on Cancer gastric cancer TNM staging system.
Surgery-related data: Surgical procedures (distal subtotal gastrectomy, proximal subtotal gastrectomy, total gastrectomy), surgical approaches (open, laparoscopic), duration of operation (min, from skin incision to skin closure), intraoperative blood loss (mL; calculated by evacuator volume and gauze weighing method), lymph node dissection extent (D1, D1+, D2), combined organ resection status, reconstruction type (Billroth I/Billroth II/Roux-en-Y gastrojejunostomy/esophagogastric anastomosis/esophagojejunal Roux-en-Y anastomosis).
Postoperative data: Placement of abdominal drainage tube and time of staying with drainage tube (day), time for first ambulation after surgery (hour, defined as the first getting out of bed, standing and walking ≥ 10 m after surgery), time for the first liquid diet intake postoperatively (hour), postoperative analgesia methods (patient-controlled intravenous analgesia, patient-controlled epidural analgesia, conventional analgesia), postoperative complications (pulmonary infec
Statistical analysis was performed with SPSS 26.0 software. Normality (Shapiro-Wilk test) and homogeneity of variance of continuous variables were tested first. Normally distributed continuous data were presented as mean ± SD, whereas independent samples t-test was used for intergroup comparison. For non-normally distributed continuous data, we presented them as median (interquartile range), and using a Mann-Whitney U test to compare between groups. Categorical data was represented as n (%), and χ2 test or Fisher’ exact test were used for the comparison between groups. Multivariate logistic regression analysis was performed for variables with P < 0.10 in univariate analysis, and forward stepwise method (likelihood ratio method) was used to screen independent risk factors of delayed gastrointestinal recovery and calculate odds ratios (OR) and 95%CI. A Nomogram prediction model for the risk of delayed gastrointestinal recovery was constructed using R 4.3.0 software rms package based on results from multivariate analysis. Discrimination of the models was assessed with the use of the area under the receiver operating characteristic (ROC), area under the curve (AUC), with AUC > 0.70 being acceptable and > 0.80 indicating good discrimination. Model calibration was evaluated with the Hosmer-Lemeshow goodness-of-fit test and a series of calibration curves, with P > 0.05 indicating a good fit for the model. Decision curve analysis (DCA) was performed to assess clinical utility. The corrected C-index value was calculated to evaluate model stability, where an internal validation with a repeated sampling of 1000 bootstrap methods was performed. All statistical tests were two sided, and P values of < 0.05 were deemed statistically significant.
Total 293 patients had radical gastrectomy, of which 193 were male (65.9%) and 100 female (34.1%), aged from 28 to 83 years (65.7 ± 11.1) years. In terms of the definition criteria for delayed gastrointestinal recovery, there were 218 cases (74.4%) in the normal gastrointestinal recovery group and 75 cases (25.6%) in the delayed gastrointestinal recovery group.
They were statistically significant differences between two groups in terms of gender (P = 0.037), age (P = 0.006), BMI classification (P = 0.032), diabetes (P = 0.042), ASA classification (P = 0.006), preoperative anemia (P = 0.017) and preoperative hypoalbuminemia (P = 0.003) (P < 005). The two groups were similar in terms of smoking history, alcohol consumption history, hypertension, coronary heart disease, COPD, cirrhosis, previous abdominal surgery history, preoperative serum sodium and potassium levels as well as fasting blood glucose level and CEA and CA19-9 (P > 0.05) (Table 1).
| Item | Normal gastrointestinal recovery group | Delayed gastrointestinal recovery group | Statistic | P value |
| Gender | χ2 = 4.366 | 0.037 | ||
| Male | 151 (69.3) | 42 (56.0) | ||
| Female | 67 (30.7) | 33 (44.0) | ||
| Age (years) | 64.7 ± 11.3 | 68.6 ± 10.2 | t = 2.771 | 0.006 |
| BMI classification | χ2 = 6.847 | 0.032 | ||
| Underweight | 28 (12.8) | 18 (24.0) | ||
| Normal | 105 (48.2) | 32 (42.7) | ||
| Overweight | 52 (23.9) | 16 (21.3) | ||
| Obese | 33 (15.1) | 9 (12.0) | ||
| Smoking history | 89 (40.8) | 36 (48.0) | χ2 = 1.200 | 0.273 |
| Alcohol consumption history | 67 (30.7) | 28 (37.3) | χ2 = 1.102 | 0.293 |
| Comorbidities | ||||
| Hypertension | 78 (35.8) | 32 (42.7) | χ2 = 1.132 | 0.287 |
| Diabetes | 38 (17.4) | 22 (29.3) | χ2 = 4.124 | 0.042 |
| Coronary heart disease | 23 (10.6) | 11 (14.7) | χ2 = 0.952 | 0.329 |
| COPD | 15 (6.9) | 8 (10.7) | χ2 = 1.115 | 0.291 |
| Cirrhosis | 12 (5.5) | 6 (8.0) | χ2 = 0.630 | 0.427 |
| Previous abdominal surgery | 34 (15.6) | 16 (21.3) | χ2 = 1.350 | 0.245 |
| ASA classification | χ2 = 7.528 | 0.006 | ||
| Grade I-II | 171 (78.4) | 47 (62.7) | ||
| Grade III | 47 (21.6) | 28 (37.3) | ||
| Preoperative anemia | 56 (25.7) | 30 (40.0) | χ2 = 5.685 | 0.017 |
| Preoperative hypoalbuminemia | 42 (19.3) | 27 (36.0) | χ2 = 8.715 | 0.003 |
| Abnormal serum sodium | 18 (8.3) | 9 (12.0) | χ2 = 0.945 | 0.331 |
| Abnormal serum potassium | 22 (10.1) | 11 (14.7) | χ2 = 1.188 | 0.276 |
| Abnormal fasting blood glucose | 35 (16.1) | 17 (22.7) | χ2 = 1.727 | 0.189 |
| Elevated CEA | 73 (33.5) | 29 (38.7) | χ2 = 0.668 | 0.414 |
| Elevated CA19-9 | 65 (29.8) | 27 (36.0) | χ2 = 1.021 | 0.312 |
There were statistically significant differences (P < 0.05) between the two groups with respect to maximum tumor diameter (P = 0.031), degree of differentiation (P = 0.019) and TNM staging (P = 0.004). No statistically significant differences in tumor location or Lauren pathological type were found between the two groups (P > 0.05) (Table 2).
| Item | Normal gastrointestinal recovery group | Delayed gastrointestinal recovery group | Statistic | P value |
| Tumor location | χ2 = 1.862 | 0.426 | ||
| Upper gastric | 58 (26.6) | 23 (30.7) | ||
| Middle gastric | 47 (21.6) | 18 (24.0) | ||
| Lower gastric | 92 (42.2) | 27 (36.0) | ||
| Diffuse type | 21 (9.6) | 7 (9.3) | ||
| Maximum tumor diameter (cm) | 4.2 ± 1.8 | 5.1 ± 2.1 | t = 3.521 | 0.031 |
| Lauren pathological type | χ2 = 0.324 | 0.518 | ||
| Intestinal | 98 (45.0) | 31 (41.3) | ||
| Diffuse | 87 (39.9) | 32 (42.7) | ||
| Mixed | 33 (15.1) | 12 (16.0) | ||
| Degree of differentiation | χ2 = 7.918 | 0.019 | ||
| Well-differentiated | 32 (14.7) | 6 (8.0) | ||
| Moderately differentiated | 95 (43.6) | 24 (32.0) | ||
| Poorly/undifferentiated | 91 (41.7) | 45 (60.0) | ||
| TNM staging | χ2 = 8.284 | 0.004 | ||
| Stage I-II | 128 (58.7) | 30 (40.0) | ||
| Stage III | 90 (41.3) | 45 (60.0) |
The two groups differed significantly regarding surgical procedure (P = 0.002), surgical approach (P = 0.046), operative time (P < 0.001), intraoperative blood loss (P = 0.001), extent of lymph node dissection (P = 0.027), combined organ resection (P = 0.008) and reconstruction method (P = 0.035) (Table 3).
| Item | Normal gastrointestinal recovery group | Delayed gastrointestinal recovery group | Statistic | P value |
| Surgical procedure | χ2 = 12.348 | 0.002 | ||
| Distal subtotal gastrectomy | 128 (58.7) | 31 (41.3) | ||
| Proximal subtotal gastrectomy | 51 (23.4) | 18 (24.0) | ||
| Total gastrectomy | 39 (17.9) | 26 (34.7) | ||
| Surgical approach | χ2 = 3.976 | 0.046 | ||
| Laparoscopic | 147 (67.4) | 41 (54.7) | ||
| Open | 71 (32.6) | 34 (45.3) | ||
| Operative time (minute) | 218.6 ± 52.3 | 257.4 ± 61.8 | t = 4.982 | < 0.001 |
| Intraoperative blood loss (mL) | 180 (120-250) | 250 (180-350) | Z = 3.327 | 0.001 |
| Extent of lymph node dissection | χ2 = 4.900 | 0.027 | ||
| D1/D1+ | 56 (25.7) | 10 (13.3) | ||
| D2 | 162 (74.3) | 65 (86.7) | ||
| Combined organ resection | 24 (11.0) | 18 (24.0) | χ2 = 7.038 | 0.008 |
| Reconstruction method | χ2 = 10.135 | 0.035 | ||
| Billroth I | 68 (31.2) | 15 (20.0) | ||
| Billroth II | 42 (19.3) | 12 (16.0) | ||
| Roux-en-Y (gastrojejunal) | 57 (26.1) | 22 (29.3) | ||
| Esophagogastric anastomosis | 32 (14.7) | 10 (13.3) | ||
| Esophagojejunal (Roux-en-Y) | 19 (8.7) | 16 (21.3) |
Statistically significant differences between the two groups were found with regard to time to first postoperative ambulation, time to first postoperative liquid diet intake and method of postoperative analgesia (P < 0.05) (P < 0.001; P = 0.002; P = 0.041 respectively). No statistically significant differences were found between two groups regarding placement of abdominal drainage tube or time for drainage tube retained (P > 0.05). The postoperative complication rate of the delayed group was 41.3% (31/75), significantly higher than that of normal group (17.4%, 38/218) (χ2 = 17.865, P < 0.001), including pulmonary infection, wound infection, abdominal infection and anastomotic leakage. Because time to first postoperative ambulation, time to first postoperative liquid diet intake, and method of analgesia administered postoperatively are all postoperative variables with uncertain temporal causality in relation to delayed gastrointestinal recovery, these variables were omitted from risk factor analysis for the prediction model (Table 4).
| Item | Normal gastrointestinal recovery | Delayed gastrointestinal recovery group (n = 75) | Statistic | P value |
| Postoperative abdominal drainage | 203 (93.1) | 72 (96.0) | χ2 = 0.811 | 0.368 |
| Drainage tube retention time (day) | 4 (3-5) | 5 (4-6) | Z = 1.740 | 0.082 |
| Time to first postoperative ambulation (hour) | 24 (18-30) | 36 (30-48) | Z = 5.824 | < 0.001 |
| Time to first liquid diet intake (hour) | 48 (36-60) | 72 (60-96) | Z = 3.092 | 0.002 |
| Postoperative analgesia method | χ2 = 6.412 | 0.041 | ||
| PCIA | 127 (58.3) | 35 (46.7) | ||
| PCEA | 68 (31.2) | 28 (37.3) | ||
| Conventional analgesia | 23 (10.6) | 12 (16.0) | ||
| Overall postoperative complications | 38 (17.4) | 31 (41.3) | χ2 = 17.865 | < 0.001 |
| Pulmonary infection | 15 (6.9) | 12 (16.0) | ||
| Wound infection | 8 (3.7) | 6 (8.0) | ||
| Abdominal infection | 6 (2.8) | 5 (6.7) | ||
| Anastomotic leakage | 4 (1.8) | 3 (4.0) | ||
| Bleeding | 3 (1.4) | 3 (4.0) | ||
| Pancreatic fistula | 2 (0.9) | 2 (2.7) |
Univariate logistic regression analysis: Univariate logistic regression analysis was performed for variables that showed statistically significant differences (P < 0.05) or clinical significance (P < 0.10) in the comparison between the two groups. For the dichotomization of continuous variables, a cutoff value of 65 years old was accepted for age according to elderly population definition in China and early study; 5 cm as maximum tumor diameter cutoff was referred from T staging standard; 200 mL as intraoperative blood loss: By clinical blood transfusion indication and previous research; whereas operative time of 240 minute as its cutoff point is based on most used clinical range and literature. Univariate analyses indicated that female gender, age ≥ 65 years, underweight, DM, ASA grade III, preoperative anemia and/or hypoalbuminemia, maximum tumor diameter ≥ 5 cm, poorly/undifferentiated subtype, TNM stage III disease, surgical procedure (distal subtotal gastrectomy as reference), open surgery type (laparoscopic surgery as reference), operative time ≥ 240 minutes and intraoperative blood loss ≥ 200 mL hypertrophy D2 Lymphadenectomy combined organ resection reconstruction mode (Billroth I mode as a reference) were associated with delayed gastrointestinal recovery (P < 0.10) (Table 5).
| Variable | β | SE | Wald χ2 | OR | 95%CI | P value |
| Female gender | 0.574 | 0.266 | 4.662 | 1.78 | 1.06-2.98 | 0.031 |
| Age ≥ 65 years | 0.612 | 0.265 | 5.338 | 1.84 | 1.10-3.09 | 0.021 |
| Underweight | 0.761 | 0.33 | 5.322 | 2.14 | 1.12-4.09 | 0.021 |
| Diabetes | 0.648 | 0.296 | 4.789 | 1.91 | 1.07-3.42 | 0.029 |
| ASA grade III | 0.803 | 0.272 | 8.721 | 2.23 | 1.31-3.81 | 0.003 |
| Preoperative anemia | 0.643 | 0.278 | 5.344 | 1.9 | 1.10-3.29 | 0.021 |
| Preoperative hypoalbuminemia | 0.852 | 0.283 | 9.07 | 2.34 | 1.35-4.07 | 0.003 |
| Maximum tumor diameter ≥ 5 cm | 0.573 | 0.264 | 4.705 | 1.77 | 1.06-2.97 | 0.03 |
| Poorly/undifferentiated | 0.689 | 0.274 | 6.319 | 1.99 | 1.16-3.41 | 0.012 |
| TNM stage III | 0.774 | 0.266 | 8.475 | 2.17 | 1.29-3.65 | 0.004 |
| Proximal subtotal gastrectomy | 0.512 | 0.335 | 2.337 | 1.67 | 0.87-3.21 | 0.126 |
| Total gastrectomy | 1.085 | 0.288 | 14.189 | 2.96 | 1.68-5.21 | < 0.001 |
| Open surgery | 0.685 | 0.266 | 6.638 | 1.98 | 1.18-3.34 | 0.01 |
| Operative time ≥ 240 minute | 0.692 | 0.267 | 6.723 | 2 | 1.18-3.38 | 0.01 |
| Intraoperative blood loss ≥ 200 mL | 0.721 | 0.268 | 7.233 | 2.06 | 1.22-3.48 | 0.007 |
| D2 Lymph node dissection | 0.598 | 0.346 | 2.988 | 1.82 | 0.92-3.59 | 0.084 |
| Combined organ resection | 0.826 | 0.311 | 7.048 | 2.28 | 1.24-4.20 | 0.008 |
| Billroth II | 0.186 | 0.398 | 0.219 | 1.2 | 0.55-2.64 | 0.64 |
| Roux-en-Y (gastrojejunal) | 0.445 | 0.368 | 1.463 | 1.56 | 0.76-3.21 | 0.226 |
| Esophagogastric anastomosis | 0.291 | 0.428 | 0.462 | 1.34 | 0.58-3.10 | 0.497 |
| Esophagojejunal (Roux-en-Y) | 1.092 | 0.398 | 7.524 | 2.98 | 1.37-6.49 | 0.006 |
Multivariate logistic regression analysis: The variables with P < 0.10 in univariate analysis were included in multivariate logistic regression analysis, and independent risk factors were screened out using forward stepwise method (likelihood ratio method). Before multivariate logistic regression, multicollinearity among the included variables was assessed using the variance inflation factor (VIF) and correlation analysis. All VIF values were less than 5, and no pairwise correlation coefficient exceeded 0.85, indicating no serious multicollinearity among the candidate predictors. As per literature, if VIFs are less than 10 which further cements that there is no serious collinearity problem (40). Multivariate logistic regression identified older age (≥ 65 years), underweight, ASA grade III, preoperative hypoalbuminemia, and TNM stage III, and total gastrectomy as independent risk factors for delayed gastrointestinal recovery (P < 0.05) (Table 6).
| Variable | β | SE | Wald χ2 | OR | 95%CI | P value |
| Age ≥ 65 years | 0.779 | 0.33 | 5.575 | 2.18 | 1.14-4.17 | 0.018 |
| Underweight | 1.054 | 0.374 | 7.953 | 2.87 | 1.38-5.97 | 0.005 |
| ASA grade III | 0.884 | 0.326 | 7.35 | 2.42 | 1.28-4.58 | 0.007 |
| Preoperative hypoalbuminemia | 0.928 | 0.336 | 7.621 | 2.53 | 1.31-4.89 | 0.006 |
| TNM stage III | 0.765 | 0.325 | 5.542 | 2.15 | 1.14-4.06 | 0.018 |
| Total gastrectomy | 1.188 | 0.35 | 11.509 | 3.28 | 1.65-6.52 | 0.001 |
According to the findings of the multivariate logistic regression analysis, 6 independent risk factors (age ≥ 65 years, underweight, ASA grade III, preoperative hypoalbuminemia, TNM stage III and total gastrectomy) were included in order to establish a Nomogram prediction model for predicting delayed gastrointestinal recovery among patients after radical gastrectomy. All predictor variables in this model were readily available preoperatively or intraoperatively, exhibiting good potential for future clinical translation (Figure 1). The AUC for evaluation of model discrimination was 0.802 (95%CI: 0.747-0.857), suggesting good discriminative ability (Figure 2). The Hosmer-Lemeshow goodness-of-fit test yielded a χ2 of 6.823 (P = 0.556), and the calibration curve showed good agreement between predicted probabilities and actual incidence (Figure 3). When the threshold probability ranged from 0.10 to 0.75, this model provided net benefit according to DCA results (Figure 4), suggesting good clinical utility. The corrected C-index on bootstrap internal validation (1000 repeated sampling) was 0.793 (95%CI: 0.736-0.850), indicating good stability and predictive ability of the model.
This study was a retrospective analysis of clinical data from 293 patients who underwent radical gastrectomy. We systematically investigated independent risk factors for delayed postoperative gastrointestinal recovery and developed a Nomogram predictive model. The study reported the incidence of delayed gastrointestinal recovery was 25.6%, which fell within the literature-reported range of 15% to 35%[10]. The multivariate analysis indicated that age ≥ 65 years, underweight status, ASA grade III, preoperative hypoalbuminemia, TNM stage III and total gastrectomy were independent predictors of delayed gastrointestinal recovery. The prediction model constructed in this study had good discrimination and calibration, which can provide scientific basis for early clinical identification of high-risk patients.
Older age is a key determinant of postoperative gastrointestinal recovery. This study revealed a 2.18-fold increased risk of delayed gastrointestinal recovery in patients aged ≥ 65 years, which is consistent with previous studies[11]. The reasons for the prolonged recovery of gastrointestinal function in elderly patients are related to multiple factors leading to impaired intestinal motility: Firstly, as the age increases, the gastrointestinal smooth muscle cell function decreases, intestinal motility decreases while neuromuscular coordination also deteriorates[12]; Secondly, Elderly patients often have various chronic diseases and a decreased basal metabolic rate. At the same time, postoperative stress response is higher and inflammatory mediators are more likely to be released in circulation which inhibits intestinal motility further[13]; In addition, the sensitivity of pain in elderly patients after surgery is increased. The use of analgesics especially opioids make it much easier to induce gastrointestinal motility disorder[14]. Thus, refined perioperative management with optimized analgesia regimens, early enteral nutritional support, and active rehabilitation exercises should be given more consideration for elderly patients.
Nutritional status substantially affects recovery after surgical intervention. Underweight (BMI < 18.5 kg/m2) and preoperative hypoalbuminemia (Alb < 35 g/L) remain independent risk factors, with an OR of 2.87 and 2.53 for delayed wound healing respectively according to this study. This finding is in line with reports from the relevant literature[15,16]. Mechanism that malnutrition causes delayed gastrointestinal recovery includes: Malnutrition impair intestinal absorption barrier function, decrease intestinal immunity increase bacterial translocation and infection risk; protein deficiency hinders gastrointestinal receiving muscle contraction ability and neurotransmitter synthesis is the abdominal cavity smoothness, direct stomach inhibiting[17]; malnutrition also affects wound-healing capacity raise complication painful anastomosis risk such as delay using time of digestive organs[18]. Thus, preoperative nutritional assessment and management is essential. Patients with malnutrition should receive nutritional support therapy for 7-14 days preoperatively in order to improve their nutritional status before surgery-a duration supported by the ESPEN guidelines on clinical nutrition in surgery[19] and by evidence that preoperative immunonutrition reduces postoperative complications including delayed GI function in gastric cancer patients[20]; furthermore, a meta-analysis demonstrated that preoperative oral nutritional supplementation was associated with significantly earlier return of bowel function in gastric cancer surgery[21]. Optimizing nutritional status not only facilitates a quicker return of gastrointestinal function, but also decreases the postoperative complications and improves the patients’ long-term prognosis[22].
ASA classification scales overall health status and surgical risk of patients. In this study, 38.4% had ASA grade III and patients aged > 40 years had a risk of delayed gastrointestinal recovery that was 2.42 times higher than ASA grade I/II group patients[15]. ASA classification patients are usually multi-system disease, poor physiological reserve capacity, poor tolerance to surgical trauma[23]. Such patients exhibit a more intense postoperative stress response, autonomic nervous system dominance with increased sympathetic tone[23], and limited blood flow to the gastrointestinal tract as well as severely inhibited intestinal motility[24]. In addition, comorbidities lead to an increased incidence of postoperative complications that delay the recovery of gastrointestinal function even more, thus a vicious circle is formed. As a result, in patients with higher ASA classification system, preoperative should be multidisciplinary comprehensive evaluation, comorbidity optimized management should be carried out, intraoperative should pay attention to hemodynamic stability maintenance, postoperative monitoring and early intervention should be strengthened.
Factors related to the tumor also play significant roles in postoperative gastrointestinal recovery. This study demon
Surgical technique is an important modifiable factor influencing gastrointestinal recovery in the postoperative period. The presence of total gastrectomy was identified in this study as the strongest independent risk factor, increasing the risk of delay by 3.28-fold. This may be due to several reasons: Total gastrectomy has the largest surgical range and trauma, requiring intraoperative esophagojejunal anastomosis with more complex surgical manipulation[26]; after surgery, the loss of gastric storage function and secretory function leads to rapid chyme entry into the small intestine, which affects normal physiological intestinal function; extensive vagotomy inherent to total gastrectomy disrupts secretion of key gastrointestinal hormones-including motilin, ghrelin, and cholecystokinin-that regulate intestinal peristalsis and the migrating motor complex, leading to delayed gastric emptying, disrupted inter-segment coordination, and prolonged ileus[27]. More careful perioperative management, such as strict intraoperative manipulation, early postoperative enteral nutrition and reasonable use of prokinetic agents should be considered for patients undergoing total gastrectomy.
In this study, 6 independent risk factors were integrated to establish a nomogram prediction model with good prediction efficacy and clarity of acquisition (preoperatively or intraoperatively), which has a satisfactory value for prospective clinical application. The model’s AUC was 0.802, showing promising discriminative ability; and calibration curve and the Hosmer-Lemeshow test showed good fit of the model, additionally DCA confirmed clinical utility of this model. Compared with previous studies[28,29], this study’s prediction model has the following advantages: First of all, we include factors comprehensively. The factors in our models involve patient characteristics (such as age and BMI), nutritional status (for instance Nutritional Risk Screening-2002 scores and serum Alb level), tumor features (including anatomic site, depth of infiltration, clinical stage and histopathological classification) and surgical procedures; secondly, all predictor variables are objective and reliable, means they can be easily collected clinically; thirdly, model had been internally validated which showed good stability. This model may assist clinicians in identifying high-risk patients preoperatively and tailoring individualized perioperative management strategies, including enhanced preoperative nutritional support or optimizations of surgical plans and intensification of postoperative care monitoring, thereby decreasing the incidence of delayed gastrointestinal recovery.
This study also has limitations. First, this was a single-center retrospective study with relatively small samples and possible selection bias; second, the model only received internal validation but requires multicenter external validation in large samples to verify its generalizability; third, not all factors affecting gastrointestinal recovery were comprehensively included in this analysis (e.g., postoperative pain scores and use of prokinetic agents); among the 293 included patients, missing data for individual variables were minimal (< 1%), and complete-case analysis was performed for any remaining missing values within each regression model, with no imputation applied; fourth, patients’ follow-up was limited in time without assessment on whether the model affects long-term prognosis[30]; fifth, the present model does not incorporate dynamic perioperative inflammatory or intestinal integrity markers such as the C-reactive protein-to-Alb ratio, neutrophil-to-lymphocyte ratio, or postoperative serum citrulline; future studies should evaluate whether inclusion of these biomarkers provides incremental predictive value. Future studies should prospectively assess multicenter patients involving larger sample sizes while establishing more potential correlations to further improve predictive values and validate the model. Additionally, subsequent studies should investigate delayed GI recovery as an independent predictor of adjuvant chemotherapy delay, disease-free survival, and health-related quality of life, to establish its prognostic significance beyond the immediate perioperative period.
The nomogram prediction model developed for predicting delayed gastrointestinal recovery following radical gastrectomy achieved a good discrimination, calibration and clinical value. It can offer scientific basis for clinical decision-making, promote rapid recovery of the patient, and lead to a better prognosis.
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