Edited by: Marilia Seelaender, University of São Paulo, Brazil
Reviewed by: Maha Gasmi, University of Manouba, Tunisia
Huma Naqeeb, Women University Mardan, Pakistan
†These authors have contributed equally to this work and share first authorship
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Rectal cancer is a highly prevalent malignant tumor, and surgery is one of the main treatment methods. Although preventive ileostomy can reduce postoperative complications, it is also prone to cause malnutrition and other problems.
To construct and validate an early postoperative home dietary management program for patients with preventive ileostomy for rectal cancer, aiming to improve their nutritional status and mitigate clinical ileostomy complications.
An evidence-based dietary management program was developed, covering dietary transition, nutrient intake, and fluid management. A non-concurrent controlled study was conducted with 66 patients at the Affiliated Hospital of Nanjing University of Chinese Medicine. The intervention group received personalized one-on-one dietary guidance (including pre-discharge assessment of dietary habits, individualized meal planning, and weekly WeChat-based follow-up for food diary reviews) in addition to routine health education, while the control group received routine education only.
At 1 month postoperatively, the intervention group showed significantly better outcomes than the control group in serum albumin (41.00 g/L vs. 38.00 g/L,
This home dietary management program can effectively improve short-term postoperative nutritional status in patients, and also plays a positive role in reducing the occurrence of HOS and PMASD.
Colorectal cancer ranks third in global incidence and second in mortality among malignant tumors. In China, its incidence ranks second and mortality fourth, accounting for 28.2% of global cases (
To cope with these issues, some ileostomy patients adjust their dietary intake by avoiding certain foods or reducing food intake to reduce stoma output or avoid issues like odor. Additionally, the lack of professional home rehabilitation dietary guidance leads to further problems. For instance, 39.7% of patients with peristomal moisture-associated skin damage (PMASD) within 1 month after surgery still consumed semi-liquid diets (
Although existing guidelines provide dietary management recommendations for ileostomy patients (
The research team consisted of 8 members: 1 head nurse from gastrointestinal oncology surgery responsible for project guidance, 2 specialist physicians responsible for disease diagnosis and treatment, 1 nutritionist responsible for reviewing and modifying the dietary management program, 3 stoma therapists responsible for patient education and follow-up management, and 1 research nurse primarily responsible for overall project coordination, consultation, and data collection. The research team held regular meetings to advance the project with close collaboration.
This study summarized evidence on dietary management interventions for patients after preventive ileostomy for rectal cancer through evidence-based methods, extracted relevant content, and formed a preliminary draft of the dietary management program. Ten experts were selected to complete the consultation, resulting in the program. Eight patients were selected for a pilot test. The program was adjusted based on pilot results, ultimately forming the final dietary management program (
Dietary management program for patients with preventive ileostomy.
| Diet type selection and recording | 1. Within 1 week after discharge, patients can consume semi-liquid diets and gradually transition to regular diets, following principles of low residue, low fat, and low fiber. Avoid spicy, irritating, and fried foods, maintain nutritional balance and dietary diversity to establish dietary tolerance and navigate the dietary transition period. 2. Use tools such as 24-h dietary recall forms, food diaries, or food frequency questionnaires to record patients' dietary intake types, quantities, and frequencies. |
| Nutrient selection | 3. Energy supply: determine energy supply based on patient needs. If HOS occurs, the patient's energy target should be increased by at least 30–50% above normal intake to compensate for intestinal losses. 4. Energy composition: 40–50% from carbohydrates, 20% from protein, and 30–40% from fat. 5. Consume starchy foods such as rice and noodles; limit high-monosaccharide foods like candy, honey, jam, jelly, and high-sugar beverages. 6. Increase protein intake: protein requirement is 1.5–2.5 g/(kg·d). 7. Use medium- and short-chain fatty acids instead of long-chain fatty acids, ensuring adequate essential fatty acids and fat-soluble vitamins. 8. Limit dietary fiber intake. Recommend soluble fiber foods such as viscous, non-fermentable, gel-forming soluble fiber supplements (e.g., psyllium husk). Reduce insoluble fiber intake from high-fiber foods (e.g., celery, asparagus), indigestible fiber peels (e.g., apples), corn, raw cabbage, dried fruits, nuts, popcorn, casing meats, mushrooms, coconut, etc., to avoid obstruction. 9. Recommend oral multivitamin and mineral supplements, such as vitamin B12, iron, calcium, liquid magnesium, zinc, manganese, and selenium. |
| Fluid management | 10. Oral fluid intake: 1,500–1,700 mL. If HOS occurs, increase daily intake by 500–750 mL above the average recommended intake for the general population. 11. Types of oral fluids: limit hypotonic fluids (e.g., water, tea, coffee, alcohol) and hypertonic fluids (e.g., fruit juice, cola) to < 1,000 mL per day. If HOS occurs, oral rehydration salts can be used. |
| Dietary behaviors | 12. Eat small, frequent meals to maintain appetite. Divide meals into 5–6 times, scheduled during the daytime to reduce nocturnal stoma output and ensure nighttime rest. 13. Avoid eating too quickly during meals; take small bites, chew thoroughly, and avoid drinking water during meals. |
| HOS assessment and monitoring | 14. Stool assessment: assess and record daily stoma excretion characteristics and volume. If stoma output >1,500 mL/day, consider HOS. 15. Urine assessment: record daily urine volume and color, ensuring urine output >1,000 mL/day. 16. Dehydration assessment: monitor for signs and symptoms of dehydration (e.g., dry mouth, decreased urine output, dark concentrated urine, dizziness when standing, significant fatigue, abdominal cramps). Seek medical attention if symptoms occur. 17. Weight monitoring: weigh at least once weekly. |
A non-concurrent controlled study was conducted in the general surgery and gastrointestinal oncology surgery wards of Nanjing University of Chinese Medicine Affiliated Hospital. Patients undergoing preventive ileostomy for rectal cancer between July 2024 and February 2025 were included. Thirty-three patients from July-November 2024 were assigned to the control group, and thirty-three patients from December 2024-February 2025 were assigned to the intervention group. Inclusion criteria: (a) Diagnosed with rectal cancer, underwent radical tumor resection with preventive ileostomy, expected survival >1 year; (b) Age 18–75 years; (c) Conscious with unimpaired communication. Exclusion criteria: (a) Eating disorders; (b) Severe primary heart, liver, lung, kidney, blood diseases or other serious conditions affecting survival; (c) Participation in other similar clinical trials. The study was approved by the Ethics Committee of Nanjing University of Chinese Medicine Affiliated Hospital (2024NL-181-02). Sample size calculation based on comparing means of two groups: n1 = n2 = 2[(μα + μβ)σ/δ]2, with α = 0.05 (two-sided), β = 0.10 (one-sided). From preliminary results, δ = 3.40, σ = 3.82, yielding n1 = n2 ≈27. Considering 20% attrition, the adjusted sample size was 33 per group (total 66).
Received routine health education. Before discharge, they received home care manuals and were educated by stoma therapists about ileostomy characteristics and dietary points. They were informed about stoma clinics and instructed to follow up regularly. Telephone follow-ups were conducted within 1 week after discharge.
In addition to the control group's intervention, they received in-depth communication with stoma therapists and nutritionists 2–3 days before discharge to understand preoperative eating habits and care needs. They received personalized one-on-one dietary guidance tailored to their eating habits and preventive ileostomy characteristics. On discharge day, stoma therapists reviewed the education and provided additional guidance as needed. Patients received a home dietary management manual and joined a stoma patient WeChat group for nutrition and dietary questions. Patients uploaded weekly food diaries and bowel movement records for monitoring.
Patient demographics and tumor-related indicators (age, gender, Body Mass Index (BMI), education level, tumor stage) were recorded. Outcome measures included primary and secondary endpoints assessed pre-intervention and 1 month post-discharge.
Nutritional indicators (serum albumin, lymphocyte count, PG-SGA, BMI). Fasting blood samples were collected in the morning and analyzed at the hospital's clinical laboratory to determine serum albumin levels and lymphocyte counts. PG-SGA were assessed by the nutritionist. BMI was calculated using the formula: BMI = Weight (kg)/Height (m)2. The nutritionist measured the patients' height and fasting weight using the Meilen hospital-specific integrated ultrasonic height and weight measuring instrument (Model: MSG003).
Incidence of HOS and PMASD within 1 month postoperatively. HOS was defined as stoma output >1,500 mL/24 h.
SPSS 25.0 was used. Normally distributed continuous data were expressed as mean±SD and analyzed with independent
A total of 66 patients were included in this study, all of whom completed the 1-month postoperative follow-up. There were no statistically significant differences in the general characteristics between the two groups (
Comparison of general characteristics.
| 0.547 | ||||
| Female | 6 (18.2) | 8 (24.2) | ||
| Male | 27 (81.8) | 25 (75.8) | ||
| Age (years), mean ± SD | 61.88 ± 8.89 | 60.03 ± 11.52 | 0.468 | |
| - | 0.492a | |||
| Single | 1 (3.13) | 0 (0.0) | ||
| Married | 31 (93.94) | 33 (100.0) | ||
| Widowed | 1 (3.13) | 0 (0.0) | ||
| 0.796 | ||||
| No | 22 (66.7) | 21 (63.6) | ||
| Yes | 11 (33.3) | 12 (36.4) | ||
| 0.071 | ||||
| No | 29 (87.9) | 23 (69.7) | ||
| Yes | 4 (12.1) | 10 (30.3) | ||
| 0.469 | ||||
| Primary school or below | 7 (21.2) | 5 (15.15) | ||
| Junior high school | 14 (42.4) | 15 (45.45) | ||
| Senior high school | 7 (21.2) | 4 (12.12) | ||
| Associate's degree | 4 (12.1) | 8 (24.24) | ||
| Bachelor's degree | 1 (3.0) | 1 (3.03) | ||
| 0.784 | ||||
| Stage I | 2 (6.1) | 2 (6.1) | ||
| Stage II | 9 (27.3) | 7 (21.2) | ||
| Stage III | 20 (60.6) | 23 (69.7) | ||
| Stage IV | 2 (6.1) | 1 (3.0) | ||
aFisher's exact test.
Comparison results of nutritional indicators between the two groups at discharge and 1 month postoperatively are shown in
Comparison of nutritional status.
| At discharg | 38.00 (35.1, 41.9) | 37.30 (35.5, 40.3) | 0.434 | ||
| At 1 month | 41.00 (39.0, 42.5) | 38.00 (36.5, 41.3) | 0.010 | ||
| At discharge | 1.20 (0.9, 1.4) | 1.08 (0.8, 1.4) | 0.530 | ||
| At 1 month | 1.30 (1.0, 1.8) | 1.10 (0.8, 1.3) | 0.009 | ||
| At discharge | 23.79 ± 3.40 | 24.91 ± 3.05 | 0.168 | cohen's d = 0.404 | |
| At 1 month | 22.45 ± 3.17 | 23.66 ± 2.81 | 0.109 | cohen's d = 0.346 | |
| At discharge | 11.97 ± 2.07 | 12.06 ± 2.81 | 0.881 | cohen's d = 0.037 | |
| At 1 month | 9.85 ± 1.33 | 10.94 ± 2.62 | 0.037 | cohen's d = 0.525 | |
Comparison results of HOS and PMASD incidence rates within 1 month postoperatively between the two groups are shown in
Incidence of HOS and PMASD (
| HOS, |
2 (6.1) | 6 (18.2) | - | 0.29 | 0.05–1.56 | 0.258a |
| PMASD, |
6 (18.2) | 8 (24.2) | 0.69 | 0.21–2.29 | 0.547 |
a:Fisher's exact test.
The development of this home dietary management program was grounded in current evidence-based guidelines and clinical best practices. It integrates key aspects such as staged dietary transition, macronutrient and micronutrient optimization, fluid and electrolyte balance, fiber modulation, eating behavior coaching, and stoma output monitoring. This comprehensive and structured approach addresses the complex nutritional needs of ileostomy patients and provides actionable strategies for home implementation.
In clinical settings, patients with ileostomy often report confusion and anxiety regarding dietary choices. Prior surveys indicate that approximately 55% of patients feel overwhelmed by postoperative dietary restrictions and uncertain about appropriate food selection (
This program addresses that gap by offering tailored, structured guidance. Through collaborative efforts between stoma therapists and clinical dietitians, the program respects preoperative eating habits while promoting gradual adaptation through weekly follow-ups. The emphasis on patient autonomy and continuous engagement helps establish self-management capabilities. These findings are aligned with previous studies (
Both groups demonstrated significant improvements in serum albumin, total lymphocyte count, and PG-SGA scores 1 month after surgery, with the intervention group showing more pronounced gains. This reinforces the nutritional benefit of structured home dietary interventions. The observed outcomes are consistent with Lin's findings (
Interestingly, BMI declined slightly in both groups at 1 month, mirroring the findings of Vasilopoulos et al. (
The high stoma output characteristic of ileostomy leads to nutrient losses—particularly protein, electrolytes, and micronutrients—contributing to protein-energy malnutrition in over half of patients (
Moreover, the program's emphasis on refined starches and low-fiber foods for output control was supported by previous research (
This study also incorporated medium- and short-chain fatty acids (MCFAs/SCFAs) as alternatives to long-chain fats, based on bile acid metabolism disturbances observed in ileostomy patients (
While the reduction in high-output stoma (HOS) incidence in the intervention group (6.06% vs. 18.18%) was not statistically significant (
The intervention emphasized behaviorally informed strategies—frequent small meals, thorough chewing, and avoidance of hypotonic fluids—to modulate intestinal transit and stoma output. While earlier studies (
Regarding peristomal moisture-associated skin damage (PMASD), while no statistically significant differences were found (18.18% vs. 24.24%,
This study used a non-concurrent controlled design, which may be subject to time bias or uncontrollable confounding factors. The lack of statistically significant differences in complication rates between groups is mainly attributed to the small sample size and low statistical power. Additionally, the follow-up period was only 1 month postoperatively, insufficient to evaluate the program's long-term effects and potential impact on ultimate tumor prognosis. Future studies should expand sample sizes and extend follow-up periods.
This study constructed and clinically validated an evidence-based, systematic, individualized, and multidisciplinary early postoperative home dietary management program addressing the common malnutrition risks in patients with preventive ileostomy. Preliminary application demonstrates that the program effectively improves short-term postoperative nutritional status (serum albumin, lymphocyte count, PG-SGA scores) and reduces HOS incidence. A positive trend was also observed in reducing peristomal moisture-associated skin damage (PMASD) incidence, though these differences did not reach statistical significance due to sample size and study design limitations. Future research with larger samples, more rigorous designs, and longer follow-up periods is needed to further validate the program's long-term effects, complication prevention efficacy, and impact on patient quality of life.
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
The studies involving humans were approved by the Ethics Committee of Nanjing University of Chinese Medicine Affiliated Hospital. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
JZ: Writing – review & editing, Writing – original draft. YS: Writing – review & editing, Writing – original draft. JL: Supervision, Writing – review & editing, Conceptualization. SW: Writing – review & editing, Data curation. WS: Writing – review & editing, Supervision. MS: Writing – review & editing, Supervision.
The author(s) declare that financial support was received for the research and/or publication of this article. This work was supported by [the Nightingale Scientific Research Project of Jiangsu Province Hospital of Chinese Medicine; Grant number (Y23025)].
We are grateful to all the medical workers and patients involved in this study.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The author(s) declare that no Gen AI was used in the creation of this manuscript.
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