1.What is the nutritional status of gastric cancer patients before surgery? The diagnosis rate of early gastric cancer in mainland China is low, only about 10%. When gastric cancer is diagnosed, most of them are already in the middle or late stage, showing wasting and loss of appetite, and some of them have combined obstruction or incomplete obstruction, so they cannot eat or can only eat a little. Patients are in a state of high consumption and low intake, usually manifesting as protein-calorie malnutrition, accompanied by anemia, hypoproteinemia, decreased immune function and coagulation dysfunction. The subsequent surgical trauma and possible chemotherapy may lead to metabolic disorders and further impairment of the body’s immune defense function, which will put gastric cancer patients at risk of secondary infection. Therefore, for gastric cancer patients with malnutrition before surgery, they should make use of the short pre-surgical time for pre-surgical nutritional support. 2. How to use the short pre-surgical time to provide nutritional support for malnourished gastric cancer patients? Pre-operative nutritional support for malnourished gastric cancer patients is very meaningful. It can make the patient’s condition more stable during surgery and the recovery after surgery more smooth. For patients who can still eat, a high-protein and high-energy diet should be given, and attention should be paid to supplementing trace elements and water-soluble and fat-soluble vitamins, and the food should be thin, soft and easy to digest, and can be eaten 4-6 times a day. Commercial enteral nutrition preparations have the advantages of comprehensive nutrition and easy digestion and absorption, and the amount of protein, fat and carbohydrate provided is also clearly indicated. For patients with obstruction who can not eat already, doctors need to use gastroscopy to help nutrition tube to duodenum or jejunum, under the control of nutrition pump, infusion of nutrition solution, while infusion of pancreatic enzyme preparation can improve the patient’s tolerance level of enteral nutrition solution. The whole protein type nutrition solution containing dietary fiber can be used, which can stimulate the proliferation of colonic mucosa and protect the intestinal mucosal barrier. Immunonutrition solution can also be used. Immunonutrition solution is a standard nutrition formula with immunonutrients such as glutamine, arginine, nucleotides, ω-3 fatty acids, etc. Immunonutrition solution not only improves the nutritional status of patients, but also helps to improve the immunity of the body. The preoperative nutritional support for gastric cancer patients is not allowed to be too long. When the effect of nutritional support is obvious, the nutritional status can be improved in 7 to 10 days. Although it takes some time to improve the nutritional status before surgery, the results obtained are extremely significant to the life of patients. 3. How to provide nutritional support for preoperative neoadjuvant chemotherapy gastric cancer patients? Pre-operative neoadjuvant chemotherapy gastric cancer patients are all intermediate or advanced stage. Before the start of neoadjuvant chemotherapy, patients are already in a state of high consumption and low intake, which is manifested as malnutrition, accompanied by anemia, hypoproteinemia, decreased immune function and coagulation dysfunction. After the start of neoadjuvant chemotherapy, the patient’s appetite further decreases. Therefore, once the diagnosis of gastric cancer is confirmed, nutritional support should be enhanced. Give high-protein and high-energy diet, requiring food to be thin, soft and easy to digest, which can be fed 4 to 6 times a day. It can also be supplemented with some commercial enteral nutrition preparations, such as Ensure Powder Flush. The nutritional reserve of the organism is an important guarantee to complete neoadjuvant chemotherapy. If in the course of neoadjuvant chemotherapy, for 7 consecutive days, the amount of food intake does not reach 60% of the normal requirement, the doctor needs to supplement some nutrition by intravenous infusion to facilitate the successful completion of the neoadjuvant chemotherapy program. 4.How to provide nutritional support for gastric cancer patients undergoing transformative chemotherapy? There are some gastric cancer patients who are considered unresectable after diagnosis, but become resectable after chemotherapy, which is called transformative chemotherapy. Translational chemotherapy allows some gastric cancer patients to be converted from unresectable to resectable, increasing resectability. Nutritional support is significant in patients with gastric cancer treated with transformative chemotherapy. Some patients with severe malnutrition who were considered unresectable after diagnosis were completely unable to eat and had extremely poor nutritional status when they were admitted to the hospital. After the chemotherapy is effective and the obstructive symptoms are relieved, the doctor places a nasal-intestinal tube under the guidance of gastroscope and gradually infuses nutritional fluid under the control of nutritional pump. If the conversion chemotherapy continues to be effective, the obstructive symptoms can sometimes be relieved and the oral diet can be resumed. The patient’s nutritional status is completely improved, which lays the foundation for further surgical treatment. Translational chemotherapy shrinks the tumor and its metastases and relieves the GI obstruction. In this way, while the tumor shrinks and can be resected, the patient’s general condition is also improved, so that the surgery can be performed safely. 5.How to provide nutritional support for gastric cancer patients undergoing palliative chemotherapy? Palliative chemotherapy refers to the systemic chemotherapy for unresectable advanced gastric cancer and unresectable recurrent gastric cancer, which aims to prolong survival and improve quality of life. Nutritional support also plays an important role in the chemotherapy of these patients. Some of these patients have combined obstruction or incomplete obstruction and are unable to eat or can only eat a small amount of food. For patients who are still able to eat some food, a high-protein, high-energy diet and oral supplementation with commercial enteral nutrition preparations are given. As much oral supplementation as possible can be given as long as the gastrointestinal tract can tolerate it. If, in the course of palliative chemotherapy, there is an obstruction to eating or if the intake of food for 7 consecutive days does not reach 60% of the normal requirement, the doctor needs to supplement nutrition by intravenous infusion to facilitate the continuation of palliative chemotherapy. If palliative chemotherapy can no longer control the tumor but exacerbate the nutritional failure, chemotherapy should be stopped and nutritional support should be provided according to specific conditions to improve the patient’s general condition. 6.Would nutritional support be given to patients with end-stage gastric cancer? For patients with end-stage gastric cancer (these patients have very little hope to reverse and resume independent feeding), although nutritional support should not be refused because of medical resources, the cost of nutritional support, expected clinical efficacy, and expectations of patients and their families should be fully considered before nutritional support is implemented. After balancing the above three points, the decision should be made again. 7.How to provide nutritional support for post-surgical gastric cancer patients? Enteral nutrition support is the first choice for gastric cancer patients after surgery. Early enteral nutritional support can be provided by using intraoperative pre-placed jejunal nutrition tube or retained nasojejunal nutrition tube. Early enteral nutrition for gastric cancer patients after surgery can be started as early as 6 hours after surgery, but most physicians reach a consensus that it should be started from the 24th to 48th hour after surgery. Some doctors give patients 250-500 ml of 5% glucose from the first postoperative day, and from the second day, use enteral nutrition solution, and then gradually increase the dosage to reach the full amount of enteral nutrition on the fifth or sixth postoperative day. In our hospital, from the first postoperative day, the enteral nutrition solution is pumped through the jejunal nutrition tube, using the infusion pump, starting with 20 ml/h at a uniform rate, and gradually increasing the pumping rate every day according to the patient’s tolerance status, generally on the fifth or sixth postoperative day, the full amount of enteral nutrition can be achieved. Early postoperative enteral nutrition requires the cooperation of parenteral nutrition (intravenous supplemental nutrition). Parenteral nutrition supplements the insufficient part of enteral nutrition to meet the nutritional needs of patients. 8. What diet is beneficial to the recovery of gastric cancer patients discharged from hospital and recuperating at home? After major or total gastrectomy, the surgical treatment of gastric cancer patients comes to an end and they need to leave the hospital to recover and recuperate at home. This stage is very important, as “three parts treatment, seven parts nourishment”. It is important to pay attention to nutritional supplementation, and also to adjust the amount and type of food as appropriate, taking into account the patient’s own tolerance to diet and stomach capacity. In short, the diet should be nutritious and easy to digest, in general, the following principles should be followed. (1) Less food and more meals: Since only a small part of stomach remains after radical resection of gastric cancer or the jejunum is substituted for stomach after total gastrectomy, the feeding capacity is obviously reduced compared with the original one, and only by increasing the number of meals can make up for the lack of food quantity and meet the body’s demand for nutrients. Therefore, patients should develop good eating habits, eat at regular times, eat regularly and quantitatively, and insist on eating less and more meals, with 5-6 meals per day being appropriate. The main food and side dishes should be thin, soft and easy to digest. Never overeat. Beijing 301 Hospital General Surgery Tang Yun (2) eat more protein-rich food: post-operative as time passes, gradually in recovery, in accordance with the clear, fluid, semi-fluid, soft food, general food order to eat. Liquid diet with rice soup, egg soup, vegetable soup, lotus root powder is appropriate. The semi-liquid diet should be high in protein, high in calories, high in vitamins, low in fat, and fresh and easy to digest. The best source of animal protein is fish. Fish protein is of high quality and easily digested and absorbed by the body, so we encourage more fish, such as yellow croaker and crucian carp. After entering the general diet, you should eat more vegetables, fruits and other foods with high fiber to keep the stool flowing smoothly. (3) Less sweets and fats: Excessive sugar intake can cause discomfort symptoms after eating, therefore, intake of overly sweet foods should be avoided. Fat energy supply should not exceed 35% of the total energy, avoid animal fat, and should choose fats that are easy to digest and absorb, such as vegetable oil, cream, egg yolk, etc. (4) Food taboos: 1) avoid eating cold, overheated, coarse and hard foods; 2) avoid eating spicy and stimulating condiments, such as pepper, mustard, etc.; 3) strictly forbid drinking strong wine, strong tea, etc.; 4) avoid overly oily and too rough foods, such as fried chicken, fries and other fried foods. (5) Prevention of anemia: appropriate use of animal liver, fresh vegetables, etc. to improve the acquisition of various vitamins and minerals. After total gastrectomy of gastric cancer, iron deficiency anemia is prone to occur, therefore, appropriate lean meat, fish, shrimp, animal blood, animal liver and foods rich in protein and iron such as dates, green leafy vegetables and sesame paste can be consumed to prevent anemia. (6) Chew and swallow slowly: the grinding function of the stomach is lacking after surgery, so the chewing function of teeth should play a more important role. For coarse and indigestible food, chew and swallow carefully and slowly.