Abstract
<title>Abstract</title> <p>Background The optimal timing and guidance method for post-pyloric enteral feeding tube placement in patients undergoing minimally invasive esophagectomy (MIE) remains uncertain. Intraoperative placement can support early enteral nutrition without a second procedure, whereas postoperative digital subtraction angiography (DSA)-guided placement provides radiological confirmation but requires patient transfer and may delay feeding initiation. This study compared perioperative outcomes between intraoperative and postoperative DSA-guided nasoenteral tube placement in patients with esophageal cancer undergoing MIE. Methods This single-center quasi-experimental comparative study included 103 patients who underwent MIE for esophageal cancer or esophagogastric junction cancer at a tertiary hospital in Suzhou, China, from October 2023 to June 2025. Patients were assigned to an intraoperative tube placement group (n = 52) or a postoperative DSA-guided placement group (n = 51). Outcomes included successful first-attempt tube placement, enteral nutrition dose and tolerance, thirst and hunger visual analogue scale scores, comfort, bowel function recovery, gastric drainage, nutritional biomarkers, hospital stay, costs and postoperative complications. Results Baseline demographic and disease characteristics were comparable between groups. Successful tube placement did not differ significantly between the DSA-guided and intraoperative groups (100.0% vs. 92.3%, P = 0.118). Compared with the intraoperative group, the DSA-guided group had lower thirst scores (2 [1–4] vs. 4 [2–6], P = 0.004), earlier first defecation after enteral nutrition (3 [2–4] vs. 4[3–5] days, P = 0.010), shorter tube dwell time (12 [9–17] vs. 18 [14-24.5] days, P < 0.001) and lower gastric drainage volume (70 [10–150] vs. 125 [22.5-262.5] mL,P = 0.039). The intraoperative group had higher comfort scores (86 [80.25–93.75] vs. 73 [70–83], P < 0.001), better early enteral nutrition tolerance (1 [0–2] vs. 2 [1–3], P = 0.005) and higher early postoperative prealbumin levels (193.43 +/- 54.20 vs. 157.57 +/- 48.20 mg/L, P = 0.001). Anastomotic leakage was more frequent in the intraoperative group (19.2% vs. 3.9%, P = 0.015), while aspiration and pulmonary infection did not differ significantly. Conclusions Intraoperative and postoperative DSA-guided nasoenteral tube placement achieved similar placement success in MIE patients. Intraoperative placement was associated with better early tolerance, higher comfort and better early prealbumin recovery, whereas DSA-guided placement was associated with earlier bowel recovery, shorter tube duration, lower gastric drainage and fewer anastomotic leaks in this non-randomized cohort. Tube placement strategy should be individualized, and the higher observed leak rate in the intraoperative group warrants cautious technical optimization and prospective confirmation.</p>