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HOME > Ann Clin Nutr Metab > Volume 17(1); 2025 > Article
Original Article Comparison of efficacy of enteral versus parenteral nutrition in patients after esophagectomy in Malaysia: a prospective cohort study
Ramizah Mohd Shariff1orcid, Sze Chee Tee1orcid, Shukri Jahit Mohammad1orcid, Khei Choong Khong2orcid
Annals of Clinical Nutrition and Metabolism 2025;17(1):41-49.
DOI: https://doi.org/10.15747/ACNM.24.016
Published online: April 1, 2025

1Department of Surgery, National Cancer Institute, Putrajaya, Malaysia

2Department of Pharmacy, National Cancer Institute, Putrajaya, Malaysia

Corresponding author: Ramizah Mohd Shariff, email: skyzlimit49@gmail.com
• Received: November 13, 2024   • Revised: November 23, 2024   • Accepted: December 24, 2024

© 2025 Korean Society of Surgical Metabolism and Nutrition · Korean Society for Parenteral and Enteral Nutrition · Asian Society of Surgical Metabolism and Nutrition · Japanese Society for Surgical Metabolism and Nutrition

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    This study aims to assess the effectiveness of enteral versus parenteral feeding in patients after esophagectomy.
  • Methods
    This a prospective cohort study of post-esophagectomy intensive care unit (ICU) patients over 12 months in the National Cancer Institute, Malaysia. Early enteral feeding followed the Enhanced Recovery After Surgery protocol, and parenteral nutrition (PN) was considered if there was a risk for conduit ischemia. It compared the effectiveness of enteral versus PN following esophagectomy, and assessed the correlations between biochemical nutritional markers and hospital lengths of stay or ventilation days.
  • Results
    It included two cohorts receiving PN (n=11) or enteral nutrition (EN) (n=11) following elective esophagectomy. Preoperative weight, body mass index, and Subjective Global Assessment were higher in the EN group (P=0.033, P=0.021, P=0.031, respectively). Nutritional interruption occurred more frequently in the EN group (63.7%) compared to the PN group (P=0.001). Mean levels of energy and protein received were 93.1 kcal/kg and 1.4 g/kg for PN versus 92.4 kcal/kg and 1.2 g/kg for EN (P=0.893 and P=0.036). The median lengths of ICU stay (P=0.688) and postoperative stay (P=0.947) between groups showed no significant difference. In addition, 30-day mortality (P=0.214) and other postoperative complications (P>0.05) were comparable in the two groups.
  • Conclusion
    Early initiation of supplementary PN due to significant interruption in EN led to higher protein intake compared to the EN group. However, there were no significant differences in postoperative outcomes, including 30-day mortality, ICU length of stay, and ventilation days. PN ensures adequate nutritional intake, especially in terms of protein delivery, without adversely affecting postoperative recovery and clinical outcomes.
  • Keywords: Complications; Enhanced recovery after surgery; Enteral nutrition; Esophagectomy; Parenteral nutrition
Background
Malnutrition affects up to 78.9% of oesophageal cancer patients, leading to higher postoperative complications and mortality [1,2]. Nutritional support, particularly enteral nutrition (EN), is crucial for better outcomes due to its lower complication rates and costs compared to parenteral nutrition (PN) [3]. While early oral feeding post-esophagectomy may shorten hospital stays and improve recovery, concerns about anastomotic leaks remain [4].
In Asia, meta-analysis study in China by Peng et al. [5] found that only 37% of patients post-esophagectomy met nutritional goals via EN alone, necessitating supplemental PN. Another study in China by Yu et al. [6] reported greater infection rates in PN patients compared to those on EN after esophagectomy. It was noted that PN group exhibited higher, the rate of systemic inflammatory response than the EN group. Although EN group is generally preferred, PN is essential in certain situation where the gastrointestinal tract unable to support enteral feeding, lowering complications and aspiration risks in specific conditions [7].
Studies have compared the effectiveness of EN and PN in achieving nutritional goals after esophagectomy, with conflicting outcomes. Worthington et al. [8] noted that PN is essential when intestinal issues prevent adequate oral or EN and can reduce mortality. Fell et al. [9] found worse nutritional outcomes when PN is delayed in critically ill infants and children. Conversely, Mudge et al. [10] reported no significant differences in energy and protein delivery between EN and PN groups. These conflicting results may be due to variations in surgical techniques, postoperative care, and patient characteristics across centres.
A systematic review and meta-analysis by Chow et al. [11] found no significant differences in overall complication rates, anastomotic leaks, or respiratory complications between EN and PN groups. The researchers emphasize that there is no observed superiority between PN and EN regarding nutrition support complications, major adverse events, and mortality outcomes. A study by Weijs et al. [12] found no significant difference in hospital stay or ventilation days between the EN and PN groups. Martinez-Ortega et al. [13] recommend a combination of EN and PN if caloric and nutrient needs cannot be adequately met through oral and enteral means alone (less than 50% of the caloric requirement) after 7 days. In cases where nutrition therapy is necessary and EN is contraindicated, such as instances of intestinal obstruction, prompt initiation of PN is advised.
While not directly related to clinical outcomes, cost-effectiveness has also been compared [14]. Studies show EN to be more cost-efficient than PN due to lower costs of enteral feeding formulations and administration [15-17].
Objectives
This study aims to compare the efficacy of EN and PN in Malaysian patients after esophagectomy by evaluating nutritional adequacy, complications, hospital stay length, and mechanical ventilation duration. Furthermore, correlation between length of stay (LOS) or ventilation duration and biochemical markers, including albumin and C-reactive protein (CRP) level, were analysed. These results will be basic data to guide optimal nutritional management in patients after esophagectomy.
Ethics statement
Institutional review board approval was obtained from National Cancer Institute, Malaysia for this study (No. 800-5/3/1), and informed consent was provided by all participants.
Study design
It was a prospective cohort study and described according to the STROBE statement available at https://www.strobe-statement.org/.
Setting
This study was done at the intensive care unit (ICU) of the National Cancer Institute, Putrajaya, Malaysia, from May 31, 2023, to May 31, 2024. Early enteral tube feeding was initiated in all post-esophagectomy patients according to the Enhanced Recovery After Surgery protocol within 24 hours of surgery [12,18]. However, in cases with risk of conduit ischemia, PN will be initiated to ensure targeted calorie and protein provision by postoperative day 5.
Participants
The study included all patients who underwent esophagectomy and were admitted to the ICU postoperatively (Fig. 1).
Variables
The primary outcomes are calories and protein level of patient following esophagectomy postoperative day 5. The secondary outcomes are biochemical nutritional markers, complications, ICU and hospital lengths of stay, ventilation days, and overall postoperative complications according to Clavien-Dindo classification.
Data sources/measurement
Demographic and clinical data were obtained from patients' medical records. Nutritional intake was monitored daily, with energy and protein intakes calculated using standard formulas. Complications were classified according to the Clavien-Dindo system [19,20].
Bias
There was no selection bias reportable.
Study size
Sample size estimation was not done since the entire target population was subjected to it.
Statistical methods
Statistical analysis was conducted using IBM SPSS version 26 [21]. Continuous variables were reported as mean±standard deviation (SD) or median (interquartile range), while categorical variables were presented as frequency and percentage. The Student t-test or Mann-Whitney U test was used to compare continuous variables between the EN and PN groups, and the chi-square test or Fisher exact test was used for categorical variables. A P-value <0.05 was considered statistically significant [22-24].
Participants
Participants’ sociodemographic characteristics are presented in Table 1. The mean ages were 60.9 years (PN) and 55.1 years (EN). The EN group had better preoperative weight, body mass index, and Subjective Global Assessment scores (P<0.05). Nutritional interruptions occurred more frequently in the EN group (63.7%), with seven patients converted to PN due to prolonged intestinal failure type I. Mean energy and protein intakes were similar between groups: PN (93.1 kcal/day, 1.4 g/kg) and EN (92.4 kcal/day, 1.2 g/kg) with P-values of 0.893 and 0.036, respectively. ICU and postoperative hospital stays, 30-day mortality, and postoperative complications did not differ significantly between groups.
Nutritional parameters and clinical outcomes between EN and PN groups are presented in Table 2. The caloric intake for both groups did not show significant differences across the days measured, as in Table 2. This pattern continued through day 7, where the mean caloric intake was 92.8 kcal (SD=11.35) for all patients, with no significant differences between groups (P=0.893). In contrast to caloric intake, total protein intake showed significant differences, particularly from day 2 onward. On day 2, the PN group had a mean protein intake of 0.9 g (SD=0.70) compared to 0.5 g (SD=0.25) for the EN group, with a significant P-value of 0.001. Levels of biochemical markers, specifically albumin and CRP, were also evaluated. While there were no significant differences in albumin levels across the days measured, value on day 3 (P=0.055) suggested a potential impact of nutritional strategy on protein status.
Postoperative complications of EN and PN groups measured according to the Clavien-Dindo system were presented in Table 3. The overall incidence of complications was similar between the EN and PN groups, with no significant differences in rates of complications (P=0.574), as in Table 3. The most common complications were of grade IIIb, occurring in 36.4% of all patients, with a higher rate in the PN group (45.4%) compared to the EN group (27.2%). As expected, the PN group experienced risk of conduit ischemia.
Albumin and CRP levels between pneumonia and non-pneumonia groups were presented in Table 4. Albumin levels did not show significant differences (P=0.302), whereas CRP levels were significantly higher in the pneumonia group (243.5 mg/L, SD=82.69) compared to the non-pneumonia group (137.4 mg/L, SD=96.58), with a P-value of 0.012, as in Table 4.
Correlation between LOS or ventilation duration and biochemical markers, including albumin and CRP level, were presented in Table 5. There is no significant correlation of LOS or ventilation days with albumin levels (P>0.05), as in Table 5.
Key results
EN group had significantly better preoperative weight, body mass index, and Subjective Global Assessment scores but experienced more nutritional interruptions (63.7%) with seven conversions to PN. Both groups achieved similar energy intake, yet PN provided significantly higher protein intake from day 2 onward. ICU and hospital stays, 30-day mortality, and overall complications were comparable, except for a higher grade IIIb complication rate in PN. Elevated CRP levels were clearly associated with pneumonia and positively correlated with longer hospital stays.
Interpretation
Caloric intake trend continued through day 7, where the PN group maintained higher protein intake, indicating that PN may be more effective in meeting protein requirements in critically ill patients [25-29]. CRP levels did not differ significantly between groups, indicating similar inflammatory responses throughout the study period [12,29-31]. Fluid balance, as measured by median values and interquartile ranges, showed no significant differences between the groups, with P-values ranging from 0.061 to 0.577, suggesting comparable fluid management strategies.
Although there was no significant correlation between LOS or ventilation days with albumin level, a significant positive correlation was found between LOS and CRP levels (P=0.049), indicating that longer hospital stays are associated with higher inflammatory markers. This suggests that monitoring CRP levels may be crucial in managing patients' nutritional needs and overall recovery [32,33].
Even though the ICU guidelines highlight early enteral feeding in the ICU among the esophagectomy cohort, this can be difficult. The challenges in managing potential gut intolerance after major surgery position such patients at risk of not achieving targeted calorie and protein goals. Potential conduit ischemia is another issue that may hinder EN tolerance [24]. If there are no major issues after surgery, especially esophagectomy, EN is acceptable, as demonstrated herein; by day 7, the EN group had achieved 92.4% of the caloric target. The PN group achieved higher protein levels throughout the observation period, with significantly higher levels from day 2 (0.9 g/kg/day vs. 0.5 g/kg/day, P=0.001) through day 7 (1.4 g/kg/day vs. 1.2 g/kg/day, P=0.036). Complication rates were similar between groups, with Clavien-Dindo grade IIIb complications observed in 45.4% of PN patients versus 27.2% of EN patients (P>0.05). This aligns with previous findings on the safety of supplementary PN [34-36]. However, 63.6% of EN patients needed modifications to their feeding strategy, compared to none in the PN group (P=0.006), indicating that supplementary PN delivers nutrition more reliably [37].
The findings of this study also support key aspects of the European Society for Clinical Nutrition and Metabolism (ESPEN) guideline implementation especially in supplementary PN timing. Significant nutritional gaps in the first 3–5 days post-surgery validate ESPEN's recommendation for supplementary PN when EN provides <50% of nutritional needs by days 3–5. This shows the importance of early assessment of EN adequacy. By consistently evaluating whether patients are meeting their nutritional targets, healthcare providers can promptly identify those at risk of nutritional deficiencies. It also highlighted the importance of achieving the protein targets, which is a common issue among ICU patients receiving EN only [33,38-40].
It is important to adopt a flexible approach to nutritional support that is tailored to individual patient characteristics. Such an approach requires healthcare providers to consider a range of patient-specific factors, including age, underlying health conditions, treatment goals, and personal preferences. Such an individualized strategy ensures that nutritional interventions are effective and aligned with the patient's overall care plan. The implementation of these recommendations can significantly improve the quality of nutritional support provided to patients, fostering better clinical outcomes and enhancing the overall effectiveness of nutritional management in various healthcare settings. By prioritizing early assessments, focusing on protein delivery, monitoring inflammatory markers, and personalizing care, clinicians can make substantial strides in addressing the nutritional needs of their patients.
The study confirms that EN and PN are equally important for early nutritional support among ICU patients, especially those recovering from major surgery. There is no significant difference in outcomes with these two methods, but an early change to PN in patients who cannot tolerate EN will support achievement of calorie and protein targets for optimal recovery. Supplementary PN and/or conversion to total PN is acceptable for patients expected to not tolerate EN well. Both of these methods demonstrate the importance of focus on nutritional support with the aims of calorie and protein targets to support patient recovery.
The results of this study provide robust empirical support for the ESPEN guidelines, which advocate for the use of supplementary PN in post-esophagectomy patients within intensive care settings. While EN remains the preferred primary strategy, the data indicate that supplementary PN is crucial in enhancing nutritional intake, particularly in terms of protein, without increasing the risk of complications. By day 7, patients receiving PN consistently achieved higher protein intake than those in the EN group, further reinforcing the effect of ESPEN on early nutritional intervention and the critical significance of adequate protein levels for recovery [28,29].
Despite similar energy intake between the two groups, the superior protein delivery in the PN group underscores the necessity of supplementary PN when EN alone fails to meet nutritional targets. This finding is especially pertinent for patients who experience interruptions in EN or are at higher nutritional risk, as evidenced by the substantial percentage of EN patients who required a transition to PN during recovery.
The study also highlights the safety and efficacy of supplementary PN, with postoperative outcomes such as ICU stay, ventilation duration, and complication rates showing no significant differences between the groups. Furthermore, the correlation between elevated CRP levels and prolonged hospital stays suggests that effective nutritional support, including supplementary PN, may mitigate inflammatory responses and enhance recovery [18].
Integrating supplementary PN in accordance with ESPEN guidelines provides a reliable method to ensure comprehensive nutritional support during the early postoperative period following esophagectomy. By addressing the nutritional deficiencies that often occur with EN alone, clinicians can potentially improve patient outcomes, including reduced complications, expedited recovery times, and improved overall clinical results. These findings enhance the body of evidence supporting a flexible and individualized approach to postoperative nutrition, positioning supplementary PN as a valuable component of patient care after esophagectomy [27].
Limitations
First, the relatively small sample size (n=22) may compromise the statistical power of the findings, potentially affecting the robustness of the conclusions. This limitation can hinder the generalizability of the results and is consistent with concerns raised in related studies. Furthermore, the non-randomized nature of the research introduces a risk of selection bias, which may affect the validity of the comparisons and outcomes. This issue has been acknowledged in previous research as well, emphasizing the need for caution when interpreting results derived from non-randomized designs. Additionally, the higher baseline nutritional risk observed in the PN group may confound the comparisons between groups. This variability in initial risk levels could potentially skew the outcome assessments, as noted in the literature. Such confounding factors must be addressed in future research to provide clearer insights into the efficacy of nutritional interventions.
Suggestion for further studies
Several avenues for future research emerge from these limitations. Large-scale, randomized controlled trials specifically focused on supplementary PN will be crucial. These studies would enhance statistical power and allow more definitive conclusions regarding the efficacy of PN in various clinical contexts. Second, the development of precise criteria for initiating supplementary PN is essential. Clear guidelines will help clinicians make informed decisions regarding patient nutrition, improving patient outcomes. Finally, further investigation into the optimal protein-to-energy ratios in supplementary PN formulations is warranted. Understanding the ideal nutritional composition can significantly impact patient recovery and overall health. By exploring these areas, future research can contribute to a more nuanced understanding of nutritional support and its role in clinical practice, ultimately leading to improved patient care.
Implications
An unexpected detail is the high calorie intake (up to 93 kcal/kg/day by day 7), which is unusually high compared to typical ICU targets (25–30 kcal/kg/day). This may reflect aggressive nutritional support in this cohort, potentially due to increased metabolic demands post-esophagectomy. The significant correlation between CRP and LOS adds a new layer, suggesting that inflammation management could be key to reducing hospital stays.
Conclusion
While EN remains the preferred initial approach, supplementary PN proves essential when EN falls short, particularly in achieving protein targets without increasing complications. It also reveals no significant differences between EN and PN groups in hospital stay, ventilation duration, or complication rates. These findings advocate for a flexible, patient-tailored nutritional strategy that aligns with ESPEN guidelines to optimize outcomes and emphasize the need for early nutritional assessment.
Fig. 1.
Comparison enteral nutrition (EN) versus parenteral nutrition (PN) on clinical outcome in esophagectomy patients. POD, postoperative day; ICU, intensive care unit; LOS, length of stay.
ACNM-24-016f1.jpg
ACNM-24-016f2.jpg
Table 1.
Sociodemographic characteristic comparison between PN and EN groups
Characteristic All (n=22) PN (n=11) EN (n=11) P-value
Age (yr), mean±SD 58.0±12.79 60.9±10.63 55.1±14.55 0.297a
Sex, No. (%) 0.647b
 Male 15 (68.2) 7 (63.6) 8 (72.7)
 Female 7 (31.8) 4 (36.4) 3 (27.3)
ASA, No. (%) 0.540b
 I 7 (31.8) 3 (27.3) 4 (36.4)
 II 11 (50.0) 5 (45.5) 6 (54.5)
 III 4 (18.2) 3 (27.3) 1 (9.1)
ECOG, No. (%) 0.078b
 0 12 (54.5) 4 (36.4) 8 (72.7)
 1 9 (40.9) 7 (63.6) 2 (18.2)
 2 1 (4.5) 0 1 (9.1)
SGA, No. (%) 0.031b
 A 10 (45.4) 2 (18.2) 8 (72.7)
 B 6 (27.3) 5 (45.5) 1 (9.1)
 C 6 (27.3) 4 (36.4) 2 (18.2)
Stage, No. (%) 0.189b
 II 2 (9.1) 0 2 (18.2)
 III 14 (63.7) 9 (81.8) 5 (45.5)
 III 1 (4.5) 0 (0.0) 1 (9.1)
 IV 1 (4.5) 1 (9.1) 0
 NA 4 (18.2) 1 (9.1) 2 (27.3)
Weight (kg), mean±SD 62.1±12.33 56.6±10.88 67.8±11.60 0.033a
BMI (kg/m2), mean±SD 23.3±3.97 21.4±2.73 25.2±4.21 0.021a
ICU stay (day), median (IQR) 3.0 (2.00–9.50) 3.0 (2.00–14.00) 2.00 (2.00–5.00) 0.688c
Hospital stay (day), median (IQR) 29.0 (15.00–43.50) 30.0 (15.00–41.00) 20.0 (15.00–61.00) 0.947c
Postoperative complication, No. (%)
 30-day mortality 3 (13.6) 3 (27.3) 0 0.214c
 Morbidity 11 (50.0) 6 (54.5) 5 (45.5) 0.670b
 Pneumonia 12 (54.5) 6 (54.5) 6 (54.5) >0.999c
 Prolonged ventilation 1 (4.5) 0 1 (9.1) >0.999c
 Re-admission to ICU 7 (31.8) 3 (27.3) 4 (36.4) >0.999c
 SSI 1 (4.5) 1 (9.1) 0 >0.999c
Change in strategy, No. (%)
 Interruption and change of feeding route - 0 7 (63.7) 0.001b

PN, parenteral nutrition; EN, enteral nutrition; SD, standard deviation; ASA, American Society of Anesthesiologists; ECOG, Eastern Cooperative Oncology Group; SGA, Subjective Global Assessment; BMI, body mass index; ICU, intensive care unit; IQR, interquartile range; SSI, surgical site infection.

aIndependent t-test was applied, significant P-value was set at 0.05.

bChi-square test was applied, significant P-value was set at 0.05.

cFisher test was applied, significant P-value was set at 0.05.

Table 2.
Comparison of nutritional parameters and clinical PN and EN groups
Characteristic All (n=22) PN (n=11) EN (n=11) P-valuea
Calorie and protein targets in ICU
 Calorie intake (kcal/kg), mean±SD
  D1 29.9±18.70 33.5±15.53 26.2±21.56 0.379
  D2 41.9±13.00 45.7±9.34 38.1±15.35 0.174
  D3 54.0±12.97 56.6±14.10 51.5±11.82 0.362
  D5 77.9±17.08 82.1±12.79 73.7±20.27 0.261
  D7 92.8±11.35 93.1±8.86 92.4±14.10 0.893
 Total protein (g/kg), mean±SD
  D1 0.5±0.35 0.6±0.38 0.4±0.37 0.121
  D2 0.7±0.31 0.9±0.70 0.5±0.25 0.001
  D3 0.9±0.31 1.0±0.27 0.7±0.26 0.008
  D5 1.1±0.29 1.3±0.28 1.0±0.24 0.034
  D7 1.3±0.21 1.4±0.20 1.2±0.18 0.036
Biochemical parameters
 Albumin (g/L), mean±SD
  D1 29.2±4.03 28.4±4.50 30.1±3.51 0.327
  D3 27.0±3.48 25.5±3.01 28.4±3.47 0.055
  D5 28.5±3.02 28.1±2.17 29.0±3.74 0.494
  D7 28.9±5.31 27.3±3.90 30.5±6.17 0.153
 CRP (mg/L), mean±SD
  D1 102.3±59.37 121.5±70.2 83.2±40.66 0.134
  D3 200.0±102.22 221.7±108.40 178.3±95.67 0.331
  D5 195.3±102.48 225.2±66.61 165.4±125.09 0.182
  D7 163.0±98.52 182.0±70.83 144.0±120.70 0.380
 Fluid balance (mL), median (IQR)
  D1 1,438 (854.3 to 1,961) 997.0 (566.0 to1,948) 1,599 (1,200 to 2,000) 0.158
  D3 439.5 (–218.0 to 798.5) 292.0 (–199.0 to 576.0) 742.0 (–674.0 to 830.0) 0.577
  D5 354.0 (–56.0 to 605.5) 580.0 (–8.0 to 900.0) 67.0 (–74.0 to 400.0) 0.061
  D7 338.0 (–30.3 to 761.5) 520.0 (194.0 to 859.0) 190.0 (–46.0 to 729.0) 0.375b

PN, parenteral nutrition; EN, enteral nutrition; ICU, intensive care unit; SD, standard deviation; CRP, C-reactive protein; IQR, interquartile range.

aIndependent t-test, significant P-value was set at 0.05.

bMann Whitney U test was applied, significant P-value was set at 0.05.

Table 3.
Postoperative complications (Clavien-Dindo system)
Grade No. (%) P-value
All (n=22) PN (n=11) EN (n=11)
0 8 (36.4) 4 (36.4) 4 (36.4) 0.574
I 0 0 0
II 3 (13.7) 1 (9.1) 2 (18.2)
IIIa 1 (4.5) 0 1 (9.1)
IIIb 8 (36.4) 5 (45.4) 3 (27.2)
IVb 1 (4.5) 0 1 (9.1)
V 1 (4.5) 1 (9.1) 0

PN, parenteral nutrition; EN, enteral nutrition.

Table 4.
Comparison of albumin and CRP levels between pneumonia and non-pneumonia groups
Biochemical parameter Mean±SD t-test (df) P-valuea
Non-pneumonia (n=10) Pneumonia (n=12)
Albumin (g/L) 27.8±2.62 29.2±3.30 –1.06 (20) 0.302
CRP (mg/L) 137.4±96.58 243.5±82.69 –2.77 (20) 0.012

CRP, C-reactive protein; SD, standard deviation; df, degree of freedom.

aIndependent t-test was applied, significant P-value was set at 0.05.

Table 5.
Correlations of LOS, ventilation duration, and biochemical markers with albumin and CRP
Correlation Correlation coefficient P-valuea
LOS vs. albumin –0.256 0.250
LOS vs. CRP 0.424 0.049
Ventilation days vs. albumin –0.190 0.397
Ventilation days vs. CRP 0.276 0.213

LOS, length of stay; CRP, C-reactive protein.

aPearson correlation was applied, significant P-value was set at 0.05.

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        Comparison of efficacy of enteral versus parenteral nutrition in patients after esophagectomy in Malaysia: a prospective cohort study
        Ann Clin Nutr Metab. 2025;17(1):41-49.   Published online April 1, 2025
        DOI: https://doi.org/10.15747/ACNM.24.016
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      Comparison of efficacy of enteral versus parenteral nutrition in patients after esophagectomy in Malaysia: a prospective cohort study
      Image Image
      Fig. 1. Comparison enteral nutrition (EN) versus parenteral nutrition (PN) on clinical outcome in esophagectomy patients. POD, postoperative day; ICU, intensive care unit; LOS, length of stay.
      Graphical abstract

      Fig. 1.

      Graphical abstract

      Comparison of efficacy of enteral versus parenteral nutrition in patients after esophagectomy in Malaysia: a prospective cohort study
      Characteristic All (n=22) PN (n=11) EN (n=11) P-value
      Age (yr), mean±SD 58.0±12.79 60.9±10.63 55.1±14.55 0.297a
      Sex, No. (%) 0.647b
       Male 15 (68.2) 7 (63.6) 8 (72.7)
       Female 7 (31.8) 4 (36.4) 3 (27.3)
      ASA, No. (%) 0.540b
       I 7 (31.8) 3 (27.3) 4 (36.4)
       II 11 (50.0) 5 (45.5) 6 (54.5)
       III 4 (18.2) 3 (27.3) 1 (9.1)
      ECOG, No. (%) 0.078b
       0 12 (54.5) 4 (36.4) 8 (72.7)
       1 9 (40.9) 7 (63.6) 2 (18.2)
       2 1 (4.5) 0 1 (9.1)
      SGA, No. (%) 0.031b
       A 10 (45.4) 2 (18.2) 8 (72.7)
       B 6 (27.3) 5 (45.5) 1 (9.1)
       C 6 (27.3) 4 (36.4) 2 (18.2)
      Stage, No. (%) 0.189b
       II 2 (9.1) 0 2 (18.2)
       III 14 (63.7) 9 (81.8) 5 (45.5)
       III 1 (4.5) 0 (0.0) 1 (9.1)
       IV 1 (4.5) 1 (9.1) 0
       NA 4 (18.2) 1 (9.1) 2 (27.3)
      Weight (kg), mean±SD 62.1±12.33 56.6±10.88 67.8±11.60 0.033a
      BMI (kg/m2), mean±SD 23.3±3.97 21.4±2.73 25.2±4.21 0.021a
      ICU stay (day), median (IQR) 3.0 (2.00–9.50) 3.0 (2.00–14.00) 2.00 (2.00–5.00) 0.688c
      Hospital stay (day), median (IQR) 29.0 (15.00–43.50) 30.0 (15.00–41.00) 20.0 (15.00–61.00) 0.947c
      Postoperative complication, No. (%)
       30-day mortality 3 (13.6) 3 (27.3) 0 0.214c
       Morbidity 11 (50.0) 6 (54.5) 5 (45.5) 0.670b
       Pneumonia 12 (54.5) 6 (54.5) 6 (54.5) >0.999c
       Prolonged ventilation 1 (4.5) 0 1 (9.1) >0.999c
       Re-admission to ICU 7 (31.8) 3 (27.3) 4 (36.4) >0.999c
       SSI 1 (4.5) 1 (9.1) 0 >0.999c
      Change in strategy, No. (%)
       Interruption and change of feeding route - 0 7 (63.7) 0.001b
      Characteristic All (n=22) PN (n=11) EN (n=11) P-valuea
      Calorie and protein targets in ICU
       Calorie intake (kcal/kg), mean±SD
        D1 29.9±18.70 33.5±15.53 26.2±21.56 0.379
        D2 41.9±13.00 45.7±9.34 38.1±15.35 0.174
        D3 54.0±12.97 56.6±14.10 51.5±11.82 0.362
        D5 77.9±17.08 82.1±12.79 73.7±20.27 0.261
        D7 92.8±11.35 93.1±8.86 92.4±14.10 0.893
       Total protein (g/kg), mean±SD
        D1 0.5±0.35 0.6±0.38 0.4±0.37 0.121
        D2 0.7±0.31 0.9±0.70 0.5±0.25 0.001
        D3 0.9±0.31 1.0±0.27 0.7±0.26 0.008
        D5 1.1±0.29 1.3±0.28 1.0±0.24 0.034
        D7 1.3±0.21 1.4±0.20 1.2±0.18 0.036
      Biochemical parameters
       Albumin (g/L), mean±SD
        D1 29.2±4.03 28.4±4.50 30.1±3.51 0.327
        D3 27.0±3.48 25.5±3.01 28.4±3.47 0.055
        D5 28.5±3.02 28.1±2.17 29.0±3.74 0.494
        D7 28.9±5.31 27.3±3.90 30.5±6.17 0.153
       CRP (mg/L), mean±SD
        D1 102.3±59.37 121.5±70.2 83.2±40.66 0.134
        D3 200.0±102.22 221.7±108.40 178.3±95.67 0.331
        D5 195.3±102.48 225.2±66.61 165.4±125.09 0.182
        D7 163.0±98.52 182.0±70.83 144.0±120.70 0.380
       Fluid balance (mL), median (IQR)
        D1 1,438 (854.3 to 1,961) 997.0 (566.0 to1,948) 1,599 (1,200 to 2,000) 0.158
        D3 439.5 (–218.0 to 798.5) 292.0 (–199.0 to 576.0) 742.0 (–674.0 to 830.0) 0.577
        D5 354.0 (–56.0 to 605.5) 580.0 (–8.0 to 900.0) 67.0 (–74.0 to 400.0) 0.061
        D7 338.0 (–30.3 to 761.5) 520.0 (194.0 to 859.0) 190.0 (–46.0 to 729.0) 0.375b
      Grade No. (%) P-value
      All (n=22) PN (n=11) EN (n=11)
      0 8 (36.4) 4 (36.4) 4 (36.4) 0.574
      I 0 0 0
      II 3 (13.7) 1 (9.1) 2 (18.2)
      IIIa 1 (4.5) 0 1 (9.1)
      IIIb 8 (36.4) 5 (45.4) 3 (27.2)
      IVb 1 (4.5) 0 1 (9.1)
      V 1 (4.5) 1 (9.1) 0
      Biochemical parameter Mean±SD t-test (df) P-valuea
      Non-pneumonia (n=10) Pneumonia (n=12)
      Albumin (g/L) 27.8±2.62 29.2±3.30 –1.06 (20) 0.302
      CRP (mg/L) 137.4±96.58 243.5±82.69 –2.77 (20) 0.012
      Correlation Correlation coefficient P-valuea
      LOS vs. albumin –0.256 0.250
      LOS vs. CRP 0.424 0.049
      Ventilation days vs. albumin –0.190 0.397
      Ventilation days vs. CRP 0.276 0.213
      Table 1. Sociodemographic characteristic comparison between PN and EN groups

      PN, parenteral nutrition; EN, enteral nutrition; SD, standard deviation; ASA, American Society of Anesthesiologists; ECOG, Eastern Cooperative Oncology Group; SGA, Subjective Global Assessment; BMI, body mass index; ICU, intensive care unit; IQR, interquartile range; SSI, surgical site infection.

      Independent t-test was applied, significant P-value was set at 0.05.

      Chi-square test was applied, significant P-value was set at 0.05.

      Fisher test was applied, significant P-value was set at 0.05.

      Table 2. Comparison of nutritional parameters and clinical PN and EN groups

      PN, parenteral nutrition; EN, enteral nutrition; ICU, intensive care unit; SD, standard deviation; CRP, C-reactive protein; IQR, interquartile range.

      Independent t-test, significant P-value was set at 0.05.

      Mann Whitney U test was applied, significant P-value was set at 0.05.

      Table 3. Postoperative complications (Clavien-Dindo system)

      PN, parenteral nutrition; EN, enteral nutrition.

      Table 4. Comparison of albumin and CRP levels between pneumonia and non-pneumonia groups

      CRP, C-reactive protein; SD, standard deviation; df, degree of freedom.

      Independent t-test was applied, significant P-value was set at 0.05.

      Table 5. Correlations of LOS, ventilation duration, and biochemical markers with albumin and CRP

      LOS, length of stay; CRP, C-reactive protein.

      Pearson correlation was applied, significant P-value was set at 0.05.

      Table 1.

      Table 2.

      Table 3.

      Table 4.

      Table 5.

      Ann Clin Nutr Metab : Annals of Clinical Nutrition and Metabolism
      © Korean Society of Surgical Metabolism and Nutrition · Korean Society for Parenteral and Enteral Nutrition
        · Asian Society of Surgical Metabolism and Nutrition · Japanese Society for Surgical Metabolism and Nutrition.
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