Nutritional Support via Jejunostomy Placed During Staging Laparoscopy for Esophagogastric Cancer: A Case Series

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors,

Thank you for the opportunity to review your manuscript, which I found highly interesting. However, I believe there are several aspects that could be strengthened to improve the robustness of the article and facilitate its suitability for publication.

The introduction adequately justifies the need to further explore this field, but it does not clearly explain why the analyzed cohort provides added value or what novel contribution it offers beyond presenting another descriptive case series. It would be advisable to expand this section by specifying which knowledge gaps the study aims to address, how it complements or extends existing evidence, and why this cohort is relevant for filling those gaps.

The manuscript describes the general criteria used for the retrospective review, but it could be improved by adding information about the clinical criteria or specific situations that led to the placement of the feeding jejunostomy during laparoscopy. It would also be useful to address the potential presence of biases in data collection prior to device placement, clarify how early discontinuation of enteral support was defined, and detail the criteria used to classify complications associated with the jejunostomy tube.

The results are clearly presented; however, they could be enriched by incorporating internal comparisons which, even within a descriptive context, would allow differentiation between early discontinuation and prolonged use, the presence or absence of complications, and changes in nutritional status with and without enteral support. Such analyses would help substantiate more robustly the concepts of limited effectiveness or potentially inappropriate placements. It would also be pertinent to clarify whether the analysis considered variability in follow-up duration among the different patients.

Author Response

Dear Reviewer 1,

We sincerely thank the Reviewer for the appreciation of our work and for the constructive comments, which have allowed us to improve the quality and clarity of the manuscript. Below is a point-by-point response to the issues raised.

Comment 1: The introduction adequately justifies the need to further explore this field, but it does not clearly explain why the analyzed cohort provides added value or what novel contribution it offers beyond presenting another descriptive case series. It would be advisable to expand this section by specifying which knowledge gaps the study aims to address, how it complements or extends existing evidence, and why this cohort is relevant for filling those gaps.

Response 1: We agree with the reviewer that the rationale needed strengthening. We have revised the introduction’s final paragraph (lines:173-179). Unlike many existing studies that primarily focus on surgical technique and complications, we emphasized that our series is "particularly notable for its nutritional focus, offering a different perspective on FJ usage" specifically regarding the discrepancy between device placement and its actual nutritional utilization in the real-world setting.

Comment 2: The manuscript describes the general criteria used for the retrospective review, but it could be improved by adding information about the clinical criteria or specific situations that led to the placement of the feeding jejunostomy during laparoscopy. It would also be useful to address the potential presence of biases in data collection prior to device placement, clarify how early discontinuation of enteral support was defined, and detail the criteria used to classify complications associated with the jejunostomy tube.

Response 2: We thank the reviewer for highlighting these important methodological aspects. We have carefully revised the methods and discussion sections to provide the requested details and clarify potential biases. Specifically:

• We have clarified the selection criteria in the methods section, please see lines 192-199.
• We implemented the limitations of the study in the discussion section, specifically bias in data collection are defined in lines 657-662.
• We have defined "early discontinuation" as the withdrawal of enteral support within the first month (as specified in the revised abstract: line 35, in the result section: line 419 and in the revised figure 1: line 424).
• We have clarified the criteria used to classify complications associated with the jejunostomy tube in lines 223-225.

Comment 3: The results are clearly presented; however, they could be enriched by incorporating internal comparisons which, even within a descriptive context, would allow differentiation between early discontinuation and prolonged use, the presence or absence of complications, and changes in nutritional status with and without enteral support. Such analyses would help substantiate more robustly the concepts of limited effectiveness or potentially inappropriate placements. It would also be pertinent to clarify whether the analysis considered variability in follow-up duration among the different patients.

Response 3: We sincerely appreciate this insightful suggestion. Following your advice, we performed an exploratory analysis by differentiating the cohort into short-term and prolonged HEN users, using the median HEN duration as a cut-off. We observed trends suggesting that the short-term usage group included a higher number of deaths and patients with continued weight loss. However, given the small sample size (n=14) and the significant confounding factors (e.g., pre-existing pathology, baseline nutritional status, and disease progression), we felt that formalizing these correlations in the text would be too speculative and potentially misleading.

Nevertheless, to address your request and present these patterns objectively:

• We modified the presentation of table 2 (see lines from 436), where cases are now stratified by the duration of enteral nutrition, highlighting the differences between less than one-month users and more than one-month users.
• To highlight changes in nutritional status with enteral support, we added specific data regarding weight variations between T1 and T2 specifically for FJ users (see lines 540-543).

Reviewer 2 Report

Comments and Suggestions for Authors

This case series includes 14 patients with esophagogastric cancer (EGC) who underwent feeding jejunostomy (FJ) during staging laparoscopy. The authors found that the effectiveness of FJ remains limited.

Major comments:

1. Lines 54 to 55 are not coherent. I suggest explaining the treatment needed for EGC patients, their complications, and how these relate to nutritional status.
2. Malnutrition, cachexia, and sarcopenia are not interchangeable. Please clarify which nutritional status the authors meant and keep them consistent throughout the study.
3. Did the hospital record have a functional capacity assessment? I suggest including this in this case series.
4. I suggest classifying the patients into the cachexia (if possible), or malnutrition criteria (i.e. based on GLIM guidelines), and analysing whether there are trends if FJ showed better improvement in patients with cachexia or severe malnutrition.
5. Discuss the results from the suggestion No. 4, including other relevant studies.
6. Line 285: I suggest including the available recommendations to minimise these complications, e.g. caregiver and patient education, hospital guidelines, and clinical guidelines.
7. Lines 292 and 310: Please include other studies/guidelines and compare the results with the other studies/guidelines.

Minor comments:

8. Please clarify the abbreviation during the first mention (i.e. BMI, CONUT, PNI).

Author Response

Dear Reviewer 2,

We wish to thank the Reviewer for the time and effort dedicated to reviewing our manuscript. We have revised the text according to your recommendations to strengthen the paper. Below is a detailed response to each comment.

 

Comment 1: Lines 54 to 55 are not coherent. I suggest explaining the treatment needed for EGC patients, their complications, and how these relate to nutritional status.

Response 1: We have rephrased the introduction to ensure better coherence, also we explicitly described the therapeutic strategies for EGC patients, their complications, and how these relate to nutritional status. Please see lines 95-125.

 

Comment 2: Malnutrition, cachexia, and sarcopenia are not interchangeable. Please clarify which nutritional status the authors meant and keep them consistent throughout the study.

Response 2: We fully agree with the reviewer regarding the importance of distinguishing these clinical entities. We have revised the manuscript to ensuring terminology consistency. Since strict diagnostic criteria for sarcopenia (i.e., CT-scan assessment of skeletal muscle mass) and cachexia (systemic inflammation combined with muscle loss) were not systematically available for all patients due to the retrospective nature of the study, we avoided using these terms as synonyms. We clarified that our study focuses on "malnutrition" (or nutritional impairment), defined mainly by nutritional screening scores (NRS-2002 and MUST), as detailed in the methods section.

 

Comment 3: Did the hospital record have a functional capacity assessment? I suggest including this in this case series.

Response 3: We agree that functional capacity is a crucial parameter for a comprehensive nutritional assessment. Unfortunately, due to the retrospective design of the study, these assessments were not systematically recorded for all patients. We have acknowledged this explicitly in the limitations section of the revised discussion, please see lines 657-662.

 

Comment 4: I suggest classifying the patients into the cachexia (if possible), or malnutrition criteria (i.e. based on GLIM guidelines), and analysing whether there are trends if FJ showed better improvement in patients with cachexia or severe malnutrition.

Comment 5: Discuss the results from the suggestion No. 4, including other relevant studies.

Response 4 and 5: We appreciate the reviewer’s suggestion to align our analysis with the GLIM criteria. We have updated the introduction (lines 126-131) to explicitly reference the GLIM framework (phenotypic and etiologic criteria). Regarding the request to analyze trends based on these classifications, we performed a retrospective assessment and found that nearly the entire cohort (12 out of 14 patients) met the GLIM criteria for malnutrition based on the available data (weight loss/BMI and disease burden). As explained in the revised discussion (lines 601-606), this high prevalence of malnutrition, combined with the small sample size, made a comparative analysis between "malnourished" and "non-malnourished" subgroups unfeasible. Furthermore, as previously mentioned, the lack of CT-based muscle mass data prevented a strict classification of sarcopenia/cachexia.

 

Comment 6: Line 285: I suggest including the available recommendations to minimise these complications, e.g. caregiver and patient education, hospital guidelines, and clinical guidelines.

Response 6: We have updated the discussion to explicitly mention preventive strategies, referencing the ESPEN guidelines on Home Enteral Nutrition, as stated in lines 626-628.

 

Comment 7: Lines 292 and 310: Please include other studies/guidelines and compare the results with the other studies/guidelines.

Response 7: We have implemented the discussion section as suggested, please see lines 634-642.

 

Comment 8: Please clarify the abbreviation during the first mention (i.e. BMI, CONUT, PNI).

Response 8: We have carefully reviewed the manuscript to ensure that all abbreviations (including BMI, CONUT, and PNI) are explicitly defined upon their first appearance in the text (Lines 25, 114, 115, 128).

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors, 

I extend my sincere gratitude for the opportunity to review your work, "Nutritional Support via Jejunostomy Placed During Staging Laparoscopy for Esophagogastric Cancer: a case series." I appreciate the considerable effort invested in addressing a topic of genuine clinical importance, the optimization of nutritional support in a vulnerable patient population. Your manuscript undoubtedly highlights a significant area of practice variation and unmet need.

However, upon a thorough and detailed review, it is my assessment that the manuscript, in its present form, requires substantial revision to meet the requisite standards for scientific publication. The current findings, while insightful as an audit of local practice, are constrained by several methodological and interpretative limitations that preclude them from forming robust conclusions.

To assist you in strengthening your work, I have structured my feedback into six principal remarks. Addressing these points comprehensively is imperative for the manuscript to realize its full potential.

1. Introduction: The introduction effectively establishes the global significance of esophagogastric cancers and the problem of malnutrition. However, the stated aim: "to describe the nutritional management and clinical outcomes" is not fully commensurate with the scale of the knowledge gap identified. A descriptive case series is inherently limited in its ability to address the "need for more comprehensive and standardized indications." I recommend reframing the manuscript's objective to more accurately reflect its nature as a practice audit and hypothesis-generating study, which would provide a more fitting foundation for the presented data.

2: Research Design & Methodology: The retrospective, single-center design and the notably small sample size (n=14) are fundamental limitations that must be more profoundly addressed. The most critical methodological shortfall is the absence of a control or comparator group. Your data indicates that 6 patients underwent staging laparoscopy without FJ placement during the same period; the exclusion of this cohort represents a missed opportunity for a comparative analysis that would have significantly strengthened the study's inferential power. I strongly urge you to include a retrospective comparison with this group regarding nutritional outcomes, treatment tolerance, and complications. Furthermore, the reliance on non-standardized sources (surgical/oncological reports) for some nutritional data introduces a risk of heterogeneity and bias that must be explicitly discussed as a limitation.

3: Results, Analysis, and Conclusions: The presentation of results is predominantly descriptive, which limits the depth of the analysis. Several key issues require attention:

• Statistical Approach: The use of means and standard deviations for highly skewed data (e.g., FJ unused for 59+/- 82 days) is statistically inappropriate and misleading. Non-parametric data should be reported as medians with interquartile ranges.

• Lack of Correlative Analysis: The manuscript would benefit from exploring relationships within the dataset, for instance, by correlating the percentage of energy needs delivered via HEN with changes in weight or nutritional status.

• Numerical Inconsistencies: A critical revision of all numerical data is required. For instance, in the abstract, the percentages provided for HEN types (32% and 64%) do not correctly sum to represent the subset of 12 patients, undermining data reliability.

• Interpretative Balance: The conclusion that FJ effectiveness "appeared limited" is an overgeneralization from a small, uncontrolled series. The discussion should more cautiously weigh the observed inefficiencies and complications against any potential benefits, avoiding definitive statements on effectiveness.

4: Figures and Tables: While the tables effectively summarize patient characteristics and FJ use, their potential is not fully leveraged. For instance, Table 2 could be enhanced to facilitate a clearer visual comparison of FJ utilizers versus non-utilizers. The figures are adequate but should be cross-referenced more precisely in the text to guide the reader.

5: English Language and Syntax: The overall language is generally clear. However, minor refinements would enhance readability.

• Grammar/Spelling: "unvoluntary weight loss" should be corrected to "involuntary weight loss."

• Syntax: The sentence in the abstract, "HEN was not started in 2 cases (14%) and was discontinued stopped early in another 2 cases," contains a redundancy. It should be revised to: "HEN was not started in 2 cases (14%) and was discontinued early in another 2 cases."

6: Overall Scientific Soundness: The core message of your work, that current practice is heterogeneous and that standardized criteria are needed, is indeed valuable. To elevate the scientific soundness, the discussion must transition from merely identifying the problem to proposing a data-informed, testable solution. I encourage you to use your findings (and the proposed comparative analysis) to suggest specific, potential criteria for FJ placement (e.g., based on MUST score, presence of dysphagia, or failure of ONS trial). Furthermore, the limitations section must be expanded to provide a candid and profound discussion of how the small sample size, retrospective design, and missing data impact the interpretation and generalizability of the results.

In conclusion, I believe your manuscript addresses a pertinent clinical question. By undertaking a substantial revision that incorporates these points most critically, the inclusion of a comparator group and a more robust statistical and interpretative framework, you have the opportunity to transform this work from a descriptive case series into a compelling call for standardized practice that could truly inform future research and clinical guidelines.

I look forward to reviewing a revised version of your manuscript.

With highest regards,

The Reviewer

Author Response

Dear Reviewer 3,

We are sincerely grateful for the time and expertise dedicated to reviewing our manuscript. We found your analysis of the methodological limitations particularly acute and constructive. We have accepted almost all your suggestions, specifically regarding the statistical approach (switching to medians), the refinement of the study’s aim, and the expansion of the limitations section. Regarding the inclusion of a control group, we have provided a detailed explanation of why we opted to maintain the focus on describing the patterns of FJ utilization in this specific institutional experience, given the inherent selection biases of a retrospective comparison. Below is our point-by-point response.

 

Comment 1: Introduction: The introduction effectively establishes the global significance of esophagogastric cancers and the problem of malnutrition. However, the stated aim: "to describe the nutritional management and clinical outcomes" is not fully commensurate with the scale of the knowledge gap identified. A descriptive case series is inherently limited in its ability to address the "need for more comprehensive and standardized indications." I recommend reframing the manuscript's objective to more accurately reflect its nature as a practice audit and hypothesis-generating study, which would provide a more fitting foundation for the presented data.

Response 1: We fully agree. We have rephrased the text to clarify that this is a descriptive study aiming to audit local practice and generate hypotheses regarding patient selection, rather than providing definitive standards. Please see line 20 in the abstract, lines 173-179 in the introduction and lines 687-690 in the conclusions.

 

Comment 2: Research Design & Methodology: The retrospective, single-center design and the notably small sample size (n=14) are fundamental limitations that must be more profoundly addressed. The most critical methodological shortfall is the absence of a control or comparator group. Your data indicates that 6 patients underwent staging laparoscopy without FJ placement during the same period; the exclusion of this cohort represents a missed opportunity for a comparative analysis that would have significantly strengthened the study's inferential power. I strongly urge you to include a retrospective comparison with this group regarding nutritional outcomes, treatment tolerance, and complications. Furthermore, the reliance on non-standardized sources (surgical/oncological reports) for some nutritional data introduces a risk of heterogeneity and bias that must be explicitly discussed as a limitation.

Response 2: We sincerely agree with the Reviewer that a comparative analysis with a control group would significantly strengthen the study. We seriously considered including the 6 patients who did not undergo FJ placement during the same period. However, we ultimately decided against this retrospective comparison for two main reasons:

• Statistical validity and selection bias: in our retrospective setting, the decision not to place a FJ in those 6 patients was driven by specific clinical judgments based on surgeon’s discretion (please see lines 192-199, integrated after reviewer’s 1 suggestion). Comparing a heterogeneous group of only 6 patients against 14 would lack sufficient statistical power and would introduce a significant selection bias, potentially leading to misleading or statistically unreliable conclusions.
• Future scope: as mentioned in our revised conclusions (lines 690-693), we believe these preliminary observations serve as a rationale for a future, larger prospective study specifically designed to compare patients with and without FJ. This future analysis, conducted on a more balanced and robust sample, will provide the high-quality evidence that the Reviewer correctly calls for.

Therefore, for the current case series, we have chosen to maintain the focus strictly on describing the patterns of utilization of the device in the selected cases, auditing our institutional practice to contribute in highlighting the need for standardized criteria.

To ensure full transparency, we have explicitly acknowledged the absence of a control group as a major limitation in the revised discussion section (lines 653-657). Furthermore, the risks of bias related to the reliance on non-standardized retrospective data sources have been explicitly discussed in the same section.

 

Comment 3: Results, Analysis, and Conclusions: The presentation of results is predominantly descriptive, which limits the depth of the analysis. Several key issues require attention:

• Statistical Approach: The use of means and standard deviations for highly skewed data (e.g., FJ unused for 59+/- 82 days) is statistically inappropriate and misleading. Non-parametric data should be reported as medians with interquartile ranges.
• Lack of Correlative Analysis: The manuscript would benefit from exploring relationships within the dataset, for instance, by correlating the percentage of energy needs delivered via HEN with changes in weight or nutritional status.
• Numerical Inconsistencies: A critical revision of all numerical data is required. For instance, in the abstract, the percentages provided for HEN types (32% and 64%) do not correctly sum to represent the subset of 12 patients, undermining data reliability.
• Interpretative Balance: The conclusion that FJ effectiveness "appeared limited" is an overgeneralization from a small, uncontrolled series. The discussion should more cautiously weigh the observed inefficiencies and complications against any potential benefits, avoiding definitive statements on effectiveness.

Response 3: We have carefully addressed each of the concerns raised regarding the data presentation and interpretation:

• Statistical Approach: We agree with Reviewer’s punctual observation. Consequently, we have replaced means and standard deviations with medians and interquartile ranges (IQR) throughout the manuscript.
• Correlative Analysis: While the small sample size (n=14) limits the statistical power for formal correlations, we have improved the visual representation of potential relationships in Table 2, where data are now stratified by the duration of enteral nutrition to help identify trends between less than one-month users and more than one-month users. In addition, to highlight changes in nutritional status with enteral support, we added specific data regarding weight variations between T1 and T2 specifically for FJ users (see lines 518-521).
• Numerical Inconsistencies: We apologize for the oversight. We have thoroughly revised all numerical data and corrected the percentages in the Abstract (line 32). The percentages now correctly reflect the subset of patients who actually initiated HEN.
• Interpretative Balance: We have rephrased our comments on the results, please see revised text at lines 38-39, 579-580, 686-689.

 

Comment 4: Figures and Tables: While the tables effectively summarize patient characteristics and FJ use, their potential is not fully leveraged. For instance, Table 2 could be enhanced to facilitate a clearer visual comparison of FJ utilizers versus non-utilizers. The figures are adequate but should be cross-referenced more precisely in the text to guide the reader.

Response 4: We appreciate the suggestion to improve the visual impact of our data. We have redesigned Table 2, as mentioned in the previous comment, please see lines from 436.

We have carefully reviewed the text to ensure that all figures and tables are precisely cross-referenced at the most appropriate points to better guide the reader through the results.

 

Comment 5: English Language and Syntax: The overall language is generally clear. However, minor refinements would enhance readability.

• Grammar/Spelling: "unvoluntary weight loss" should be corrected to "involuntary weight loss."
• Syntax: The sentence in the abstract, "HEN was not started in 2 cases (14%) and was discontinued stopped early in another 2 cases," contains a redundancy. It should be revised to: "HEN was not started in 2 cases (14%) and was discontinued early in another 2 cases."

Response 5: We have implemented the requested linguistic corrections: the term "unvoluntary weight loss" has been corrected to "involuntary weight loss" throughout the manuscript. The redundancy in the abstract has been removed, and the sentence now reads: "HEN was not started in 2 cases (14%) and was discontinued in the first month in another 2 cases.".

 

Comment 6: Overall Scientific Soundness: The core message of your work, that current practice is heterogeneous and that standardized criteria are needed, is indeed valuable. To elevate the scientific soundness, the discussion must transition from merely identifying the problem to proposing a data-informed, testable solution. I encourage you to use your findings (and the proposed comparative analysis) to suggest specific, potential criteria for FJ placement (e.g., based on MUST score, presence of dysphagia, or failure of ONS trial). Furthermore, the limitations section must be expanded to provide a candid and profound discussion of how the small sample size, retrospective design, and missing data impact the interpretation and generalizability of the results.

Response 6: We appreciate this constructive feedback aimed at elevating the clinical impact of our work.

• Proposed Criteria: In the revised discussion, we have now included a concrete, data-informed proposal for patient selection (lines 669-680). Specifically, we referenced a recent algorithm proposed in a paper co-authored by members of our research group. This publication describes a strategic framework to identify EGC patients who would most likely benefit from FJ placement, based on the NRS-2002 score and clinical markers like severe dysphagia or overt malnutrition. By incorporating this framework, we aim to transition from a descriptive audit to a proactive, testable clinical approach.
• Expanded Limitations: We have significantly expanded the limitations section (lines 652-663) in line with Reviewer’s valuable considerations.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for addressing all comments.

Author Response

We sincerely thank the Reviewer for the positive feedback and for taking the time to review our revised manuscript. We are pleased to learn that the changes made have satisfactorily addressed all the concerns raised.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for the detailed revision of your manuscript and for your thoughtful response to my initial critique. I acknowledge the significant improvements made, particularly the correction of the statistical approach and the more cautious framing of the study's conclusions.

I wish to acknowledge and commend the considerable effort and scholarly rigor evident in this revision. The implementation of key methodological improvements, most notably, the systematic adoption of medians and interquartile ranges for data presentation, the correction of numerical inconsistencies, and the significant, candid expansion of the limitations section, has markedly enhanced the manuscript's statistical integrity and transparency. Furthermore, the refined framing of the study's aim as a practice audit and the integration of a proposed, testable algorithm for patient selection successfully elevate the discussion from mere description to a more forward-looking, hypothesis-generating contribution. These changes are substantial and reflect a deeply engaged revision process.

However, I must reiterate that the definitive choice to exclude any form of comparator group, including a basic descriptive characterization of the six patients who underwent staging laparoscopy without jejunostomy placement, remains the most substantial limitation. While I understand your concerns regarding selection bias and statistical power, this absence fundamentally confines your analysis.

Without even a descriptive benchmark, any observation regarding "suboptimal utilization" or "clinical benefit" is made in an informational vacuum. The manuscript effectively audits the process of FJ use, but it cannot contextualize the outcome of this practice. Therefore, I must once more strongly recommend, at a minimum, the inclusion of a descriptive table or summary of the excluded cohort. This would not necessitate complex comparative statistics but would provide the essential context for readers to interpret the patterns you so carefully describe in your case series.

This addition is crucial for the manuscript to fulfill its potential as a meaningful contribution to the literature on this topic.

Sincerely,

The Reviewer

Author Response

We sincerely thank the Reviewer for the appreciative words and for acknowledging the effort dedicated to this revision. We are particularly pleased that the methodological improvements were well received. We have carefully addressed your final remaining concern regarding the excluded cohort to further strengthen the manuscript's context.

Comment: I must reiterate that the definitive choice to exclude any form of comparator group, including a basic descriptive characterization of the six patients who underwent staging laparoscopy without jejunostomy placement, remains the most substantial limitation. While I understand your concerns regarding selection bias and statistical power, this absence fundamentally confines your analysis.

Without even a descriptive benchmark, any observation regarding "suboptimal utilization" or "clinical benefit" is made in an informational vacuum. The manuscript effectively audits the process of FJ use, but it cannot contextualize the outcome of this practice. Therefore, I must once more strongly recommend, at a minimum, the inclusion of a descriptive table or summary of the excluded cohort. This would not necessitate complex comparative statistics but would provide the essential context for readers to interpret the patterns you so carefully describe in your case series.

Response: We have seriously considered this request and reviewed the available clinical and operative records for the six patients who underwent staging laparoscopy without FJ placement. Since the retrospective data extraction was specifically designed to describe patients who met inclusion criteria, specific nutritional parameters were not analyzed for this excluded cohort, making a formal comparative table unfeasible. However, to address the request for context, we have added a new paragraph in the Results section (lines 184-189) to qualitatively characterize this group based on the retrieved records. We clarified that the exclusion of these patients was consistent with the discretionary criteria described in our methods. Specifically, the review highlighted that the majority of these patients, including those with intraoperative findings of peritoneal carcinomatosis, were managed with Oral Nutritional Supplements (ONS) or oral immunonutrition. Among the remaining cases, we observed specific clinical conditions such as severe coagulopathy or referral to external centers for experimental protocols.