Published online Sep 16, 2026. doi: 10.12998/wjcc.126192
Revised: September 3, 2026
Accepted: September 15, 2026
Published online: September 16, 2026
Processing time: 53 Days and 0.8 Hours
Malnutrition is a common and potentially modifiable risk factor among patients undergoing gastrointestinal oncology surgery and is associated with increased postoperative complications, prolonged hospital stay, delayed functional reco
Core Tip: Early nutritional assessment, individualized nutritional optimization, and multidisciplinary care within enhanced recovery after surgery pathways can improve recovery and reduce postoperative complications after gastrointestinal oncology surgery. These strategies may also help address modifiable contributors to readmission, although direct evidence for an independent reduction in 30-day readmissions remains limited. Procedure-specific pathways, digital monitoring, and precision nutrition represent important areas for further research.
- Citation: Thakur N, Goel S, Agrawal H, Gupta N. Perioperative nutrition and multidisciplinary care in gastrointestinal oncology surgery: Evidence-based strategies to enhance recovery and inform readmission prevention. World J Clin Cases 2026; 14(26): 126192
- URL: https://www.wjgnet.com/2307-8960/full/v14/i26/126192.htm
- DOI: https://dx.doi.org/10.12998/wjcc.126192
Gastrointestinal malignancies, including cancers of the esophagus, stomach, pancreas, liver, biliary tract, and colorectum, remain a leading cause of cancer-related morbidity and mortality worldwide[1]. Surgical resection remains the primary curative treatment for localized disease and is frequently combined with neoadjuvant or adjuvant therapy. Despite advances in surgical techniques, minimally invasive procedures, anesthesia, and perioperative care, postoperative complications occur in approximately 20%-50% of patients undergoing major gastrointestinal resections. These compli
Malnutrition is common among patients with gastrointestinal malignancies and represents one of the few potentially modifiable factors associated with postoperative outcomes[3]. Its prevalence ranges from 20% to 80%, depending on tumor site and stage, with particularly high rates reported in esophageal, gastric, and pancreatic cancers. Reduced oral intake, cancer cachexia, systemic inflammation, gastrointestinal obstruction, malabsorption, and treatment-related toxicity contribute to weight loss, skeletal muscle depletion, and impaired physiological reserve before surgery. The metabolic response to major surgery further accelerates protein catabolism and insulin resistance, potentially aggravating sarcopenia and increasing the risk of postoperative complications and delayed recovery[4].
Perioperative nutritional care has consequently evolved from a supportive intervention for established malnutrition to an integral component of modern surgical management[5]. Nutritional risk assessment, timely correction of nutritional deficits, preservation of skeletal muscle mass, early postoperative feeding, and continued nutritional support during recovery are increasingly incorporated into multidisciplinary perioperative pathways. These principles are central to enhanced recovery after surgery (ERAS), which integrates coordinated, evidence-based interventions to attenuate sur
Current recommendations from the ERAS Society[7], the European Society for Clinical Nutrition and Metabolism (ESPEN)[8], and other professional organizations provide guidance for nutritional and metabolic management around major gastrointestinal surgery. However, recommendations are distributed across procedure-specific ERAS pathways, clinical nutrition guidelines, and disease-specific literature, while the strength and directness of evidence vary consi
This narrative review synthesizes evidence on nutritional and multidisciplinary strategies across the perioperative continuum of gastrointestinal oncology surgery, encompassing preoperative nutritional optimization and prehabilitation, intraoperative metabolic and supportive strategies, postoperative nutritional management, multidisciplinary rehabi
This narrative review was conducted to synthesize current evidence on perioperative nutritional and multidisciplinary care strategies for adults undergoing gastrointestinal oncology surgery, with particular emphasis on interventions that influence postoperative recovery, nutritional rehabilitation, and unplanned 30-day hospital readmission. A structured literature search was performed in PubMed/MEDLINE, EMBASE, Scopus, and Google Scholar for English-language publications from January 1, 2005 to June 30, 2026. The final database searches were completed on June 30, 2026; an additional manual reference search was completed in July 2026. Publications identified through the additional search were considered only when they met the predefined eligibility criteria or represented landmark evidence specifically retained for historical context.
The search strategy combined controlled vocabulary and free-text terms related to gastrointestinal malignancies, perioperative nutrition, ERAS, prehabilitation, immunonutrition, enteral nutrition (EN), parenteral nutrition (PN), sarcopenia, multidisciplinary care, postoperative recovery, and readmission. The principal concepts were combined using Boolean operators (AND/OR). The database-specific strategies are summarized in Table 1. Reference lists of relevant systematic reviews, meta-analyses, guidelines, consensus statements, and landmark clinical trials were also screened manually to identify additional eligible publications.
| Database | Search period | Search strategy |
| PubMed/MEDLINE | January 1, 2005 to June 30, 2026 | (“gastrointestinal cancer” OR “gastrointestinal neoplasms” OR “esophageal cancer” OR “gastric cancer” OR “colorectal cancer” OR “pancreatic cancer” OR “liver cancer” OR “hepatic resection”) AND (“nutrition” OR “nutritional support” OR “oral nutritional supplements” OR “enteral nutrition” OR “parenteral nutrition” OR “immunonutrition” OR “prehabilitation” OR “sarcopenia” OR “myosteatosis”) AND (“Enhanced Recovery After Surgery” OR ERAS OR “perioperative care” OR “multidisciplinary care” OR “postoperative recovery” OR “hospital readmission”). Filters: English language, human studies, adults |
| EMBASE | January 1, 2005 to June 30, 2026 | Equivalent combination of Emtree terms and free-text keywords relating to gastrointestinal malignancies, perioperative nutrition, nutritional support, ERAS, prehabilitation, immunonutrition, sarcopenia, multidisciplinary care, postoperative recovery, and readmission |
| Scopus | January 1, 2005 to June 30, 2026 | Title, abstract, and keyword search using combinations of gastrointestinal cancer, perioperative nutrition, nutritional support, ERAS, prehabilitation, immunonutrition, sarcopenia, postoperative recovery, and readmission |
| Google Scholar | January 1, 2005 to June 30, 2026 | Broad keyword searches combining gastrointestinal cancer, perioperative nutrition, ERAS, nutritional support, sarcopenia, prehabilitation, postoperative recovery, and readmission. The first 200 results ranked by relevance for each search combination were screened |
| Additional manual search | Through July 2026 | Reference lists of eligible articles, systematic reviews, meta-analyses, ESPEN guidelines, ERAS Society guidelines, and relevant international consensus documents were screened for additional eligible studies and landmark publications |
Eligible publications included randomized controlled trials (RCTs), prospective and retrospective observational studies, systematic reviews, meta-analyses, consensus statements, and international clinical practice guidelines evaluating perioperative nutritional interventions or multidisciplinary recovery strategies in adult patients undergoing gastrointes
Titles and abstracts were screened for relevance, followed by full-text assessment of potentially eligible publications. Screening and selection were performed by the review team, with disagreements regarding eligibility or interpretation resolved through discussion and consensus among the authors. Relevant information was extracted from eligible publi
Priority was given to high-quality evidence, including RCTs, systematic reviews, meta-analyses, contemporary ESPEN and ERAS Society guidelines, and landmark studies that established or substantially influenced current perioperative nutritional practice. The evidence was organized according to the perioperative continuum: Preoperative nutritional assessment and optimization, prehabilitation, intraoperative management, postoperative nutritional care, multidisciplinary recovery, transition of care after hospital discharge, procedure-specific nutritional considerations, implementation barriers, and future directions.
For the purposes of this review, readmission primarily refers to unplanned hospital readmission within 30 days after discharge. Particular emphasis was placed on readmissions attributable to nutritional deterioration, inadequate oral intake, dehydration, gastrointestinal dysfunction, postoperative complications, or deficiencies in transitional care. Where studies did not directly evaluate readmission, outcomes such as postoperative complications, length of stay, nutritional status, functional recovery, or tolerance of adjuvant therapy were considered intermediate outcomes that may influence readmission risk, rather than being interpreted as direct evidence of reduced readmission.
The strength of evidence supporting major recommendations was categorized descriptively rather than as a formal GRADE assessment. Classification considered study design, methodological strength, consistency of findings across studies, directness to gastrointestinal oncology surgery, magnitude and clinical relevance of reported effects, and endorsement by contemporary international guidelines. Recommendations supported by multiple RCTs, consistent systematic reviews or meta-analyses, and/or strong international guideline endorsement were categorized as high-quality evidence. Recommendations supported by limited RCT data, well-conducted observational studies, or evidence with some inconsistency or indirectness were categorized as moderate-quality evidence. Interventions supported primarily by preliminary studies, small cohorts, heterogeneous evidence, or rapidly evolving technologies were classified as emerging evidence. Recommendations based predominantly on expert consensus, established clinical practice, or limited direct clinical evidence were classified as expert opinion. These categories are intended to provide a transparent qualitative summary of the available evidence and should not be interpreted as formal evidence certainty ratings.
Malnutrition is a common and potentially modifiable determinant of outcomes in patients undergoing gastrointestinal oncology surgery. Its reported prevalence ranges from 20% to 80%, depending on tumor site and disease stage, with particularly high rates among patients with esophageal, gastric, and pancreatic cancers[9]. Although nutritional impair
Malnutrition extends beyond weight loss and encompasses protein-energy deficiency, micronutrient depletion, sarcopenia, impaired immune function, and reduced functional capacity. These abnormalities diminish the ability to tolerate surgical stress and have been associated with postoperative infectious and non-infectious complications, delayed wound healing, prolonged hospitalization, delayed initiation or completion of adjuvant therapy, and poorer long-term outcomes[11]. Accordingly, nutritional status should be considered a dynamic perioperative risk factor rather than a static preoperative characteristic, with assessment and intervention continuing throughout the surgical and oncological pathway.
Cancer cachexia is a multifactorial metabolic syndrome characterized predominantly by progressive skeletal muscle depletion, with or without loss of adipose tissue, that cannot be completely reversed by conventional nutritional support alone. Persistent systemic inflammation, involving mediators such as interleukin-6, tumor necrosis factor-α, and inter
Major gastrointestinal surgery amplifies these metabolic abnormalities through activation of the neuroendocrine and inflammatory stress responses. Increased secretion of cortisol, catecholamines, and glucagon, together with inflammatory mediator release, promotes gluconeogenesis, muscle protein breakdown, and postoperative insulin resistance[13]. Early postoperative intake may be further restricted by ileus, nausea, delayed gastric emptying, pain, or procedural considerations, thereby prolonging negative nitrogen balance and functional decline[14]. The distinction between pre-existing cancer-related catabolism and potentially modifiable postoperative nutritional deficits is therefore clinically important, because nutritional therapy is most effective when integrated with strategies that reduce surgical stress, restore gastroin
Assessment of body composition has expanded the evaluation of nutritional and functional risk in gastrointestinal oncology beyond conventional measures such as body weight and body mass index (BMI)[15]. Sarcopenia, characterized by reduced skeletal muscle quantity together with impaired muscle strength and/or physical performance, is associated with increased postoperative morbidity, pulmonary complications, prolonged hospitalization, and poorer survival across several gastrointestinal malignancies[16].
Muscle quality provides additional prognostic information. Myosteatosis, characterized by increased fat infiltration within skeletal muscle, is associated with impaired muscle function and adverse outcomes even when muscle quantity is relatively preserved[17]. Sarcopenic obesity represents another clinically important phenotype in which excess adiposity coexists with reduced skeletal muscle mass or quality. Because adiposity may obscure substantial depletion of lean tissue, reliance on BMI alone can underestimate nutritional and functional risk[18]. Integration of body composition with nutritional screening therefore provides a more comprehensive assessment of physiological reserve and may help iden
Poor nutritional status adversely affects multiple dimensions of postoperative recovery. Malnourished patients have increased rates of surgical-site infection, pneumonia, intra-abdominal infection, wound complications, and anastomotic complications, reflecting impaired immune function, reduced substrate availability, and impaired tissue repair. Preope
Nutritional impairment may also contribute to prolonged hospitalization, delayed gastrointestinal recovery, reduced mobility, functional decline, and increased risk of unplanned readmission. However, the strength of evidence differs according to the outcome and intervention: Associations between nutritional impairment and postoperative morbidity are relatively well established, whereas direct evidence that correction of nutritional deficits independently reduces 30-day readmission remains more limited. Common nutrition-related contributors to readmission include dehydration, inadequate oral intake, gastrointestinal dysfunction, and progressive functional deterioration. Nutritional impairment may also compromise tolerance of adjuvant chemotherapy, contributing to treatment interruptions, dose reductions, or premature discontinuation[20]. These observations support routine nutritional assessment before surgery and continued surveillance during postoperative and oncological treatment.
Early identification of nutritional risk permits intervention before severe nutritional deterioration develops and should begin at cancer diagnosis, with reassessment at key stages of the perioperative pathway. Current guidelines support systematic nutritional screening in patients undergoing major gastrointestinal cancer surgery because clinical appearance and body weight alone may underestimate malnutrition and muscle depletion[21].
The Nutritional Risk Screening 2002 is widely used in hospitalized patients and is recommended by ESPEN for identifying individuals who may benefit from nutritional intervention. It incorporates parameters related to nutritional status, disease severity, and age[22]. The Patient-Generated Subjective Global Assessment is particularly useful in oncology because it incorporates weight change, dietary intake, gastrointestinal symptoms, functional status, and patient-reported information to characterize nutritional risk[23]. The Subjective Global Assessment remains a practical clinical tool for categorizing malnutrition severity and informing individualized nutritional management[24].
Body composition assessment complements validated nutritional screening by identifying occult muscle depletion in patients with apparently preserved body weight or BMI[25]. Computed tomography-based assessment at the third lumbar vertebral level, using routinely acquired staging images, is an established method for quantifying skeletal muscle and assessing muscle quality, including sarcopenia and myosteatosis[26]. Its integration into routine oncological imaging pathways offers an opportunity to move from conventional nutritional screening toward more objective assessment of metabolic and functional reserve.
Biochemical parameters such as serum albumin, prealbumin, and C-reactive protein may provide useful contextual information but should not be interpreted as standalone measures of nutritional status because they are influenced by systemic inflammation, hydration, hepatic function, and the acute-phase response[27]. Nutritional assessment is therefore most informative when validated screening tools, dietary and clinical assessment, functional status, body composition, and relevant laboratory findings are considered together[28]. This multidimensional approach provides the foundation for risk-adapted perioperative management, including nutritional optimization, prehabilitation, early postoperative feeding, and intensified post-discharge surveillance in patients at highest risk.
ERAS has transformed perioperative care from procedure-specific management toward standardized, evidence-based pathways designed to attenuate surgical stress and accelerate functional recovery[29]. Initially developed in colorectal surgery, ERAS principles have subsequently been applied across esophageal, gastric, pancreatic, hepatic, and colorectal oncology surgery. Across these settings, higher ERAS adherence is generally associated with fewer postoperative com
The physiological rationale for ERAS is closely linked to the metabolic consequences of major surgery. Abdominal surgical trauma induces insulin resistance, systemic inflammation, protein catabolism, and gastrointestinal dysfunction, promoting loss of lean body mass and delayed recovery. ERAS pathways combine interventions intended to attenuate these responses, preserve physiological function, and facilitate early restoration of normal activity and nutritional intake. Consistent with this approach, ESPEN recommendations emphasize that nutritional care should commence before surgery and continue throughout the postoperative period[31].
Key nutritional and metabolic components of ERAS include early identification of nutritional risk, avoidance of unne
The evidence base is particularly well established in colorectal surgery, where randomized trials and meta-analyses have demonstrated reductions in postoperative complications, earlier recovery of gastrointestinal function, and shorter hospital stay with ERAS implementation[33]. ERAS pathways have also demonstrated favorable outcomes following gastric, esophageal, pancreatic, and hepatic surgery, although the evidence base and individual pathway components vary between procedures[34]. Accordingly, ERAS should be viewed as an adaptable framework rather than a uniform protocol, with nutritional strategies modified according to surgical anatomy, baseline nutritional risk, and anticipated postoperative gastrointestinal function.
An important strength of ERAS is that recovery is achieved through the cumulative effect of multiple complementary interventions rather than reliance on a single nutritional strategy. Preoperative nutritional screening identifies patients requiring targeted optimization, while carbohydrate management, appropriate fluid therapy, minimally invasive surgery, opioid-sparing analgesia, early mobilization, and early oral or enteral feeding collectively reduce physiological stress and facilitate nutritional recovery. The relative contribution of individual components remains difficult to isolate because most ERAS studies evaluate bundled pathways rather than independent interventions.
Successful ERAS implementation also depends on multidisciplinary coordination among surgeons, anesthesiologists, dietitians, nurses, physiotherapists, pharmacists, and oncologists. Higher compliance with ERAS elements is associated with improved clinical outcomes, emphasizing the importance of standardized pathways, education, multidisciplinary communication, and regular audit[35]. This implementation dimension is particularly relevant to nutritional care, be
ERAS therefore provides the organizational and physiological framework within which perioperative nutritional care can be integrated across the surgical pathway. Its emphasis on early risk identification, attenuation of surgical stress, preservation of muscle and gastrointestinal function, early restoration of oral or EN, and continuity of care provides the foundation for individualized nutritional rehabilitation in gastrointestinal oncology. The subsequent sections examine the evidence for individual components of this pathway, distinguishing established recommendations from areas supported by moderate or emerging evidence.
The preoperative period provides a critical opportunity to identify and address nutritional and functional deficits before major gastrointestinal oncology surgery. Routine nutritional screening should be performed early, ideally at cancer diagnosis or when surgery is planned, with comprehensive assessment of patients identified as being at nutritional risk. Current ESPEN and ERAS recommendations support targeted nutritional intervention in patients with malnutrition or significant nutritional risk, and a period of preoperative nutritional therapy should be considered when surgery can be safely delayed, particularly in patients with severe nutritional impairment[36]. The objective is not simply to increase body weight but to improve nutritional adequacy, preserve skeletal muscle, and optimize physiological reserve before the metabolic stress of surgery.
Preoperative optimization should extend beyond nutritional supplementation to address the broader determinants of surgical resilience. Prehabilitation is a multimodal strategy combining nutritional optimization with physical exercise, functional conditioning, and, where appropriate, psychological support. Exercise-based interventions may improve aerobic capacity, muscle strength, and functional status, while nutritional support provides the substrate required for preservation or restoration of lean tissue. Together, these interventions aim to increase physiological reserve, improve tolerance to surgical stress, reduce postoperative morbidity, and facilitate earlier functional recovery[36].
The intensity and duration of prehabilitation should be individualized according to nutritional risk, sarcopenia or frailty, tumor-related symptoms, anticipated surgical magnitude, and the time available before surgery. Patients with severe malnutrition, substantial preoperative weight loss, or marked functional impairment may derive particular benefit from intensified nutritional and exercise interventions, although the optimal duration and composition of prehabilitation remain incompletely defined. Thus, prehabilitation should complement rather than delay urgent oncological surgery when postponement would compromise cancer treatment. The principal studies underpinning contemporary periope
| Ref. | Study design | Population | Intervention | Primary outcome (s) | Effect estimate | Limitations | Key clinical message |
| Braga et al[37], 1999 | Prospective, randomized, double-blind phase III RCT | 206 patients undergoing colorectal, gastric, or pancreatic cancer surgery | Perioperative immunonutrition containing arginine, RNA, and ω-3 fatty acids vs standard enteral formula | Postoperative infectious complications; hospital stay | Infections: 14% vs 30% (P = 0.009); hospital stay: 11.1 days vs 12.9 days (P = 0.01) | Single immunonutrition formulation; mortality was not significantly different | Perioperative immunonutrition reduced postoperative infectious complications and hospital stay |
| Gianotti et al[38], 2002 | Prospective randomized controlled trial | 305 patients undergoing gastrointestinal cancer surgery | 5 days of preoperative immunonutrition vs the same preoperative treatment plus postoperative jejunal immunonutrition vs conventional care | Postoperative infections; hospital stay | Infections: 13.7% vs 15.8% vs 30.4%; hospital stay: 11.6 days vs 12.2 days vs 14.0 days | Included patients with < 10% preoperative weight loss; applicability to severely malnourished patients are uncertain | Five days of preoperative immunonutrition produced outcomes comparable to perioperative administration and was superior to conventional care for infectious morbidity and hospital stay |
| Lassen et al[39], 2008 | Multicentre randomized controlled trial | 447 patients undergoing major upper gastrointestinal surgery | Early oral feeding vs nil-by-mouth strategy with jejunostomy feeding | Major complications; bowel recovery; hospital stay | No increase in anastomotic complications; earlier recovery and shorter hospital stay | Open-label design; limited to upper gastrointestinal surgery | Early oral feeding can be safely implemented after major upper gastrointestinal surgery in appropriately selected patients and supports ERAS-based recovery |
| Lewis et al[40], 2009 | Systematic review and meta-analysis of 13 RCTs; 1173 patients | Patients undergoing gastrointestinal surgery | Early enteral nutrition (< 24 hours) vs delayed feeding | Mortality; complications; hospital stay | Lower mortality and shorter hospital stay; trend toward fewer complications | Heterogeneity in surgical procedures and feeding protocols | Early enteral nutrition should be initiated when clinically feasible after gastrointestinal surgery |
| Weimann et al[41], 2025 | ESPEN Clinical Practice Guideline | Adult patients undergoing elective and emergency surgery | Evidence-based perioperative nutritional recommendations | Guideline recommendations | Not applicable | Guideline based on synthesis of available evidence rather than a primary clinical study | Nutritional screening, timely nutritional therapy, and integration of nutritional care within ERAS are recommended components of perioperative management |
Identification of nutritional risk should begin as soon as surgery is planned, allowing sufficient time for targeted inter
Assessment should incorporate recent unintentional weight loss, dietary intake, BMI, gastrointestinal symptoms affecting food intake, functional status, and disease severity. Validated tools such as the Nutritional Risk Screening-2002, Patient-Generated Subjective Global Assessment, and Subjective Global Assessment can facilitate standardized identification of nutritional risk. Assessment of body composition using routine staging computed tomography can provide additional information by identifying sarcopenia and myosteatosis that may remain undetected despite a normal or elevated BMI. Laboratory parameters such as serum albumin and inflammatory markers may provide complementary information but should be interpreted in the context of inflammation, hydration, and the underlying disease rather than as isolated measures of nutritional status[42].
Patients with substantial unintentional weight loss, inadequate dietary intake, low BMI, marked skeletal muscle depletion, or established malnutrition should undergo prompt nutritional intervention before surgery whenever clinically feasible. Early risk stratification also permits prioritization of patients for intensified nutritional support and prehabilitation, particularly when the anticipated surgical procedure is associated with a high metabolic or nutritional burden. The objective is to improve nutritional adequacy and preserve lean body mass while avoiding unnecessary delay of time-sensitive oncological treatment[42].
Evidence level: High-quality evidence for routine nutritional screening and targeted nutritional intervention in patients identified as nutritionally at risk, based on international guideline recommendations and supporting clinical evidence.
The objectives of preoperative nutritional therapy are to restore energy and protein adequacy, preserve skeletal muscle, support immune function, and improve tolerance to major surgery. The intensity, route, and duration of nutritional sup
Oral nutritional supplements: Oral nutritional supplements (ONS) are generally the preferred initial strategy for patients who are able to eat but cannot meet their nutritional requirements through habitual dietary intake. High-protein, energy-dense formulations can increase energy and protein intake without necessarily replacing regular meals and are particularly useful in patients with inadequate oral intake or increased nutritional requirements. In patients with severe nutritional risk, nutritional therapy should be provided for an appropriate preoperative period when surgery can safely be deferred; a period of approximately 7-14 days is commonly recommended in severely malnourished patients[43].
Protein intake should be individualized according to nutritional status, body composition, renal function, and clinical circumstances, with approximately 1.2-2.0 g/kg/day considered appropriate for many patients requiring nutritional optimization[43]. Adequate energy provision should accompany protein supplementation to minimize continued cata
Evidence level: Moderate-quality evidence for individualized preoperative nutritional supplementation, with stronger support in patients at high nutritional risk than in well-nourished patients.
EN: EN is preferred when oral intake remains inadequate and the gastrointestinal tract is functional. Access should be selected according to the anatomical site of disease, anticipated duration of nutritional support, aspiration risk, and planned operation, and may include nasogastric, nasojejunal, gastrostomy, or jejunostomy feeding. Patients with eso
Compared with PN, enteral feeding maintains gastrointestinal tract use and is generally associated with fewer infectious complications when the gut is functional. Accordingly, EN should be preferred over PN whenever adequate oral intake cannot be achieved and enteral feeding is feasible[44]. However, the route and timing should be individualized, particularly in patients with obstruction, severe intolerance, aspiration risk, or complex upper gastrointestinal anatomy.
Evidence level: High-quality evidence supporting EN as the preferred route when oral intake is inadequate and gastrointestinal function permits feeding.
PN: PN should be considered when oral and enteral routes are contraindicated or insufficient to meet nutritional requirements. Relevant clinical situations include intestinal obstruction, severe malabsorption, prolonged ileus, high-output enterocutaneous fistulae, intestinal ischemia, or inability to establish an adequate enteral route. In severely malnourished patients who cannot be adequately nourished enterally, preoperative PN for approximately 7-14 days may be considered, even when this requires a short postponement of surgery[45].
In appropriately selected severely malnourished patients, preoperative PN can improve nutritional status and reduce postoperative complications. However, its use requires careful monitoring because PN may be associated with catheter-related infection, metabolic disturbances, electrolyte abnormalities, and other nutrition-associated complications. PN should therefore not routinely replace feasible oral or EN but should be reserved for patients in whom EN is contraindicated or inadequate[45].
Evidence level: Moderate-quality evidence for preoperative PN in severely malnourished patients who cannot be adequately nourished by the enteral route; evidence is less supportive of routine PN in patients who can achieve ade
Prehabilitation extends perioperative care beyond nutritional support by preparing patients physically and psychologically for major surgery. It typically combines exercise, nutritional optimization, and psychological support with the aim of improving functional reserve, preserving skeletal muscle, reducing postoperative morbidity, and facilitating recovery.
Exercise: Exercise is a key component of prehabilitation. Programs incorporating aerobic exercise, resistance training, flexibility exercises, and inspiratory muscle training can improve cardiopulmonary fitness, preserve skeletal muscle mass, and enhance postoperative functional recovery[46]. Benefits have been reported with relatively short interventions of 2-6 weeks, although the magnitude of benefit varies according to baseline functional status and the type of surgery. Inspi
Nutritional support during prehabilitation: Exercise should be accompanied by adequate energy and protein intake because nutritional adequacy is essential for an effective anabolic response to exercise and preservation of muscle mass. Dietary counselling, correction of micronutrient deficiencies, optimization of protein intake, and oral nutritional supplementation should therefore be individualized according to nutritional risk and functional status. Combined nutritional and exercise interventions may provide greater improvements in muscle strength and physical performance than either strategy alone, particularly among patients with sarcopenia or frailty[48] (moderate-quality evidence).
Psychological support: Psychological preparation addresses factors that may influence dietary intake, treatment ad
Immunonutrition refers to specialized nutritional formulations containing immune-modulating substrates such as arginine, omega-3 fatty acids, nucleotides, glutamine, and antioxidants. These formulations are intended to modulate the inflammatory response, support immune function, maintain intestinal barrier integrity, and promote tissue repair.
Evidence from randomized trials and meta-analyses suggests that preoperative administration of arginine-containing immunonutrition for approximately 5-7 days may reduce postoperative infectious complications and hospital stay, particularly in patients undergoing major gastrointestinal cancer surgery. However, the magnitude of benefit varies between studies according to patient selection, formulation, timing, and the comparator used, and a consistent effect on mortality or long-term survival has not been demonstrated[50] (moderate-quality evidence).
Importantly, the evidence for immunonutrition should be distinguished from the broader evidence supporting nutri
Accordingly, immunonutrition should be considered as one component of a broader nutritional optimization strategy, alongside correction of nutritional deficits, adequate protein and energy delivery, exercise-based prehabilitation, and appropriate ERAS implementation, rather than as a substitute for these interventions.
The intraoperative period influences postoperative nutritional recovery by affecting gastrointestinal function, metabolic stress, pain, fluid balance, and the timing of oral or enteral feeding. Within ERAS pathways, intraoperative management aims to minimize physiological disturbance and facilitate rapid restoration of normal function. Key strategies include goal-directed fluid therapy, minimally invasive surgery, opioid-sparing analgesia, appropriate glycaemic management, selective use of enteral feeding access, and avoidance of unnecessary tubes and drains. Collectively, these measures can facilitate earlier mobilization, recovery of gastrointestinal function, and nutritional intake[52].
Perioperative fluid management aims to maintain adequate tissue perfusion while avoiding both hypovolaemia and fluid overload. Excessive intravenous fluid administration can contribute to intestinal and tissue edema, impaired gastrointes
Goal-directed fluid therapy individualizes intravenous fluid administration according to physiological and dynamic haemodynamic parameters, with the objective of maintaining euvolaemia and adequate end-organ perfusion. By avoiding unnecessary fluid loading and limiting tissue and intestinal edema, goal-directed fluid therapy may facilitate recovery of gastrointestinal function and earlier tolerance of oral or EN[53].
Current ERAS principles favour balanced crystalloids and individualized fluid administration rather than fixed-volume replacement strategies. In adequately volume-resuscitated patients, vasopressors may be used to maintain arterial pressure rather than administering additional intravenous fluid. Randomized trials and meta-analyses have demonstrated that individualized haemodynamic management can reduce postoperative complications and facilitate recovery following major abdominal surgery, although the magnitude of benefit varies according to patient population, monitoring strategy, and definition of goal-directed fluid therapy[53] (high-quality evidence).
Surgical stress induces insulin resistance, hyperglycaemia, and increased protein catabolism, all of which may adversely affect postoperative recovery. Perioperative hyperglycaemia has been associated with increased infectious complications and impaired wound healing, including in patients without pre-existing diabetes. Conversely, excessive glycaemic control may result in hypoglycaemia and should therefore be avoided.
ERAS-based perioperative care supports avoidance of marked hyperglycaemia through appropriate monitoring and individualized insulin therapy when required. Glycaemic management should account for pre-existing diabetes, nu
Minimally invasive surgery, including laparoscopic and robotic approaches, reduces surgical trauma compared with conventional open surgery and is an important component of ERAS pathways. Reduced tissue injury is associated with less postoperative pain, lower opioid requirements, earlier mobilization, and faster recovery of gastrointestinal function, thereby facilitating earlier resumption of oral intake.
Benefits of minimally invasive surgery have been demonstrated across colorectal, gastric, hepatic, pancreatic, and esophageal procedures, with shorter hospital stays and fewer wound-related complications reported in appropriately selected patients. Importantly, minimally invasive surgery should be considered within an integrated ERAS pathway rather than as an isolated intervention. Earlier functional recovery may help reduce the cumulative postoperative energy and protein deficit and facilitate timely initiation of adjuvant treatment.
Patients with pre-existing malnutrition, frailty, or sarcopenia may particularly benefit from strategies that minimize surgical stress and facilitate early mobilization. However, the feasibility and magnitude of benefit depend on tumor stage, procedure complexity, patient factors, and surgical expertise. When technically feasible and oncologically appropriate, minimally invasive surgery should therefore be incorporated into the overall strategy for nutritional and functional recovery[54] (high-quality evidence).
Effective analgesia is essential for nutritional recovery because uncontrolled pain can limit deep breathing, mobilization, participation in physiotherapy, and oral intake. At the same time, excessive opioid administration can cause nausea, vomiting, sedation, constipation, and delayed gastrointestinal motility, thereby interfering with early feeding and rehabi
ERAS pathways therefore emphasize multimodal, opioid-sparing analgesia using combinations of paracetamol, non-steroidal anti-inflammatory drugs where appropriate, regional analgesic techniques, and local anesthetic infiltration. Transversus abdominis plane (TAP) blocks can provide abdominal wall analgesia and reduce opioid requirements following selected abdominal procedures. Thoracic epidural analgesia remains an option for selected patients undergoing major open upper abdominal or thoracic procedures, although its benefits must be balanced against hypotension, urinary retention, motor impairment, and the potential impact on mobilization.
The choice between epidural analgesia, TAP block, wound infiltration, and other regional techniques should therefore be individualized according to the surgical approach and patient characteristics. By reducing opioid exposure while maintaining effective analgesia, multimodal analgesia can facilitate earlier mobilization and gastrointestinal recovery and may indirectly support earlier nutritional intake (moderate-quality evidence).
Early EN is preferred after surgery whenever the gastrointestinal tract is functional. In patients undergoing complex upper gastrointestinal procedures or those expected to have prolonged impairment of oral intake, intraoperative place
A nasojejunal tube provides temporary post-pyloric feeding and may be used after esophagectomy, gastrectomy, and pancreaticoduodenectomy when delayed gastric emptying or concerns regarding proximal gastrointestinal reconstruc
A feeding jejunostomy provides more secure enteral access for patients anticipated to require prolonged nutritional support, particularly after selected major upper gastrointestinal resections or in patients with severe preoperative nutritional compromise. However, routine placement exposes patients to procedure-related complications, including infection, leakage, bowel obstruction, volvulus, and tube dysfunction. Current practice therefore favours selective rather than routine placement based on anticipated nutritional requirements, surgical procedure, and individual patient risk[56] (moderate-quality evidence).
Avoidance of unnecessary tubes and drains is an established ERAS principle because these devices may cause discomfort, restrict mobilization, and delay functional recovery without providing demonstrable benefit in routine cases.
Routine nasogastric decompression has been associated with delayed return of bowel function, pulmonary complications, discomfort, and delayed oral feeding. Randomized trials and systematic reviews indicate that omission or early removal of nasogastric tubes does not increase anastomotic leakage or other major complications in most elective gastro
The use of prophylactic abdominal drains has similarly become more selective. Although drains may be useful for selected patients at risk of postoperative collections or anastomotic or pancreatic leaks, routine placement may impair mobilization and increase discomfort and drain-related complications. Evidence from colorectal and gastric surgery does not support routine drainage in uncomplicated procedures. Pancreatic surgery represents an important exception in which selective drain placement remains relevant because of the risk of postoperative pancreatic fistula; where drains are used, early removal based on clinical assessment and drain amylase levels may reduce drain-related morbidity[58] (moderate-quality evidence).
Overall, selective rather than routine use of tubes and drains, combined with appropriate fluid management, glycaemic control, minimally invasive surgery, and opioid-sparing analgesia, supports early restoration of gastrointestinal function and facilitates timely nutritional rehabilitation within ERAS pathways.
Postoperative nutritional management is central to recovery after gastrointestinal cancer surgery. Pain, nausea, postope
Early oral feeding is a fundamental component of ERAS pathways and should be initiated as soon as clinically feasible rather than waiting for complete resolution of postoperative ileus or return of bowel sounds. Randomized trials have demonstrated that early oral feeding can facilitate earlier gastrointestinal recovery, reduce postoperative morbidity, and shorten hospital stay without increasing anastomotic complications in appropriately selected patients[59] (high-quality evidence).
The progression of oral intake should nevertheless be individualized according to the surgical procedure, gastrointes
ONS provide a practical means of increasing energy and protein intake when conventional dietary intake is insufficient. High-protein, energy-dense formulations are particularly useful in patients with preoperative malnutrition, sarcopenia, persistent postoperative weight loss, or inadequate dietary intake. ONS can be continued after discharge when patients remain unable to meet nutritional requirements through food alone.
Continued supplementation has been associated with improved nutritional intake and may help limit postoperative weight loss and support nutritional recovery, although the magnitude of benefit varies according to baseline nutritional risk, adherence, and duration of supplementation[60] (moderate-quality evidence). Dietitian-led counselling can improve adherence by tailoring the type, volume, timing, and duration of supplementation to individual tolerance and nutritional requirements.
EN is preferred when oral intake remains inadequate and the gastrointestinal tract is functional. Feeding may be administered through a nasojejunal tube, feeding jejunostomy, or other established enteral access according to the surgical procedure and anticipated duration of nutritional support.
Patients undergoing esophagectomy, total gastrectomy, pancreaticoduodenectomy, and other major upper gastroin
The decision to initiate and advance EN should nevertheless be individualized according to gastrointestinal tolerance, haemodynamic stability, aspiration risk, and the presence of complications such as anastomotic disruption or intestinal obstruction. Enteral feeding should complement, rather than unnecessarily delay, progression toward oral nutrition.
PN is reserved for patients in whom oral and EN are contraindicated, insufficient, or poorly tolerated. Indications include prolonged postoperative ileus, intestinal obstruction, severe malabsorption, high-output enterocutaneous fistulae, bowel ischemia, intestinal failure, or persistent failure to achieve adequate nutritional intake despite appropriate enteral support[45].
PN should be considered according to the patient’s baseline nutritional status, expected duration of inadequate intake, and clinical trajectory. In patients at high nutritional risk, prolonged inability to meet nutritional requirements warrants earlier consideration of PN, whereas routine use in patients who can tolerate adequate oral or EN is not justified (high-quality evidence).
Adequate protein and energy delivery is essential after major gastrointestinal surgery because the postoperative stress response increases protein catabolism and promotes loss of skeletal muscle. Nutritional targets should therefore be individualized according to body composition, baseline nutritional status, inflammatory burden, renal and hepatic func
ESPEN recommendations generally support energy provision in the range of approximately 25-30 kcal/kg/day and protein intake of approximately 1.2-2.0 g/kg/day, with adjustment according to individual clinical circumstances[61] (moderate-quality evidence). Regular assessment of actual intake is important because prescribed targets do not necessa
Postoperative immunonutrition has primarily been investigated as part of a perioperative strategy, rather than as an isolated postoperative intervention. Meta-analyses have reported reductions in infectious complications and, in some populations, hospital stay following major gastrointestinal cancer surgery. However, benefits vary according to nutri
The available evidence therefore supports selective continuation or use of immunonutrition in appropriately selected high-risk or malnourished patients rather than routine administration to all patients[62] (moderate-quality evidence). Importantly, postoperative immunonutrition should not substitute for adequate energy and protein delivery or delay early oral and enteral feeding.
Postoperative ileus is an important barrier to nutritional recovery because it delays oral intake, prolongs dependence on intravenous support, and may increase hospital stay. Prevention is best approached through a multimodal ERAS strategy rather than reliance on a single intervention. Minimally invasive surgery, goal-directed fluid management, opioid-sparing analgesia, early mobilization, avoidance of routine nasogastric decompression, correction of electrolyte abnormalities, and early oral or enteral feeding collectively facilitate restoration of gastrointestinal function.
Adjunctive measures such as chewing gum may provide additional benefit in selected patients, while pharmacological strategies including prokinetic agents or alvimopan may be considered in specific clinical settings[63] (moderate-quality evidence). The effectiveness of individual interventions varies according to the surgical procedure and patient popula
Overall, postoperative nutritional management should follow a step-up, patient-centred approach: Early oral intake whenever feasible, supplementation when dietary intake is inadequate, EN when oral feeding is insufficient but the gastrointestinal tract remains functional, and PN when enteral strategies are contraindicated or inadequate. Continuous reassessment is essential to prevent persistent nutritional deficits and to facilitate progression toward functional and nutritional recovery.
Recovery after gastrointestinal cancer surgery depends on coordinated multidisciplinary care extending from preope
Recovery after major gastrointestinal cancer surgery requires simultaneous management of nutritional, functional, medical, and psychological factors. These domains are closely interdependent: Inadequate nutrition contributes to muscle loss and impaired rehabilitation, while pain, immobility, gastrointestinal dysfunction, and treatment toxicity can further compromise nutritional intake.
A multidisciplinary approach enables timely nutritional assessment, early recognition of complications, individualized rehabilitation, effective symptom control, and coordinated discharge planning. Communication among surgical, anesthe
Importantly, multidisciplinary care extends beyond hospitalization. Continued nutritional and functional recovery influences patients' ability to tolerate and complete adjuvant therapy, maintain independence, and return to normal activities. The objective of recovery should therefore extend beyond hospital discharge to restoration of nutritional adequacy, functional independence, and readiness for further oncological treatment.
Successful recovery after gastrointestinal cancer surgery requires coordinated contributions from healthcare professionals with complementary expertise. Surgeons lead perioperative decision-making, select appropriate operative strategies, identify and manage postoperative complications, and coordinate recovery with other members of the multidisciplinary team.
Anaesthesiologists contribute through individualized haemodynamic management, multimodal and opioid-sparing analgesia, prevention and treatment of postoperative nausea and vomiting, and other perioperative measures that faci
Dietitians are central to nutritional management. Their responsibilities include nutritional assessment, individualized dietary counselling, prescription and monitoring of ONSs and enteral or PN, monitoring of nutritional targets, and post-discharge follow-up. Their role is particularly important after upper gastrointestinal and pancreatic procedures, where altered anatomy or digestive dysfunction may produce persistent nutritional problems.
Nursing staff provide continuous bedside monitoring of oral intake, nutritional support, hydration, gastrointestinal symptoms, mobilization, and postoperative complications. They also reinforce patient education and facilitate communi
Early rehabilitation complements nutritional therapy by preserving physical function and limiting postoperative deconditioning. Prolonged immobilization after major gastrointestinal surgery accelerates skeletal muscle loss and increases the risk of pulmonary and thromboembolic complications, particularly among patients with pre-existing sarcopenia or frailty[64].
Mobilization should begin on the day of surgery or the first postoperative day whenever clinically feasible and should progress according to individual tolerance. Structured rehabilitation incorporating ambulation, respiratory physiotherapy, muscle strengthening, and progressive exercise promotes restoration of functional capacity and may improve gastrointestinal and pulmonary recovery and shorten hospital stay[64] (moderate-quality evidence).
Adequate analgesia is essential for successful rehabilitation. ERAS pathways favour multimodal, opioid-sparing analgesia to facilitate deep breathing, mobilization, participation in physiotherapy, and oral intake while minimizing opioid-related nausea, sedation, constipation, and impaired gastrointestinal motility[64] (moderate-quality evidence).
The goal of rehabilitation should be functional independence rather than simply hospital discharge. Nutritional ade
Evidence supporting multidisciplinary perioperative care is strongest when multidisciplinary management is delivered as part of a structured ERAS pathway. Studies evaluating ERAS implementation consistently demonstrate that greater adherence to pathway components is associated with improved recovery, including fewer postoperative complications and shorter hospital stay, without evidence of increased mortality or clinically important readmission in appropriately implemented pathways.
Dietitian-led nutritional care can improve nutritional assessment, achievement of nutritional targets, and individualized management of postoperative dietary problems, while structured rehabilitation supports mobility and functional recovery. Coordinated discharge planning can maintain continuity of nutritional and rehabilitative care after hospita
Multidisciplinary management may also support timely initiation and continuation of adjuvant therapy by minimizing avoidable nutritional and functional deterioration. Improvements in patient-reported outcomes, including functional status, quality of life, and satisfaction with care, have additionally been reported, although the magnitude and consis
Thus, multidisciplinary care should be regarded not as a collection of parallel interventions but as an integrated reco
Successful postoperative nutritional recovery depends not only on the provision of adequate nutritional support but also on perioperative measures that facilitate gastrointestinal function, metabolic stability, mobilization, and tolerance of oral or EN. Within ERAS pathways, multimodal analgesia, appropriate fluid and electrolyte management, perioperative glycaemic control, early mobilization, and avoidance of unnecessary tubes and catheters collectively reduce factors that can delay nutritional recovery. Although these interventions are not nutritional therapies themselves, their effects on gastrointestinal motility, metabolic stress, functional recovery, and ability to achieve nutritional targets make them important components of an integrated perioperative strategy.
Effective pain control is essential for nutritional and functional recovery because uncontrolled postoperative pain limits mobilization, respiratory function, gastrointestinal activity, and oral intake. Conversely, excessive opioid administration may cause nausea, vomiting, constipation, sedation, and opioid-induced ileus, thereby delaying gastrointestinal recovery and nutritional advancement[65].
ERAS pathways therefore emphasize multimodal, opioid-sparing analgesia using combinations of acetaminophen, non-steroidal anti-inflammatory drugs where appropriate, local anesthetic techniques, and regional analgesia according to the procedure and patient characteristics. Epidural analgesia and TAP blocks can reduce systemic opioid requirements while providing effective analgesia[66]. Their effects on gastrointestinal recovery may vary according to the surgical procedure and analgesic technique; therefore, regional analgesia should be integrated with an overall opioid-sparing strategy rather than considered as an isolated intervention. By facilitating mobilization, deep breathing, and participation in rehabilitation while limiting opioid-related gastrointestinal adverse effects, multimodal analgesia indirectly supports earlier oral or EN and functional recovery.
Surgical stress induces insulin resistance and hyperglycaemia, which may adversely affect immune function, wound healing, and postoperative recovery. Perioperative hyperglycaemia has been associated with an increased risk of infectious complications, including surgical-site and other postoperative infections, particularly in patients undergoing major abdominal surgery.
ERAS-based perioperative care therefore emphasizes avoidance of both significant hyperglycaemia and hypoglycaemia through individualized glucose monitoring and appropriate insulin therapy. Glycaemic management should account for pre-existing diabetes, nutritional intake, enteral or PN, and the metabolic stress associated with major surgery. Avoidance of excessive fasting and early restoration of nutritional intake may also reduce metabolic instability.
Optimal glycaemic control should therefore be regarded as a component of metabolic optimization rather than as an isolated glucose target. Maintaining stable glucose concentrations while avoiding hypoglycaemia may support immune function, reduce complications, and facilitate recovery and nutritional rehabilitation.
Urinary catheters are commonly placed during major gastrointestinal surgery for monitoring urine output and managing selected patients. Prolonged catheterization, however, increases the risk of urinary tract infection, restricts mobility, and causes patient discomfort[67].
Current ERAS pathways recommend early catheter removal, generally within 24-48 hours when clinically appropriate, while allowing longer catheterization in selected patients such as those undergoing complex pelvic procedures or those with epidural-related urinary retention or ongoing haemodynamic instability[68]. Early removal facilitates ambulation and rehabilitation and reduces catheter-associated complications. Although urinary catheter management has no direct nutritional effect, earlier mobilization and reduced postoperative complications may facilitate gastrointestinal recovery and progression toward oral intake.
Patients undergoing gastrointestinal cancer surgery are at increased risk of venous thromboembolism because of malig
ERAS pathways recommend pharmacological thromboprophylaxis, generally with low-molecular-weight heparin, together with mechanical measures when indicated. Extended pharmacological prophylaxis for up to four weeks is recommended after major abdominal or pelvic cancer surgery in patients with increased thrombotic risk[70]. Prevention of thromboembolic complications supports uninterrupted mobilization and rehabilitation and thereby indirectly contri
Maintenance of appropriate fluid and electrolyte balance is essential for gastrointestinal and metabolic recovery. Both excessive fluid administration and inadequate replacement may impair tissue perfusion, gastrointestinal motility, and organ function.
ERAS pathways favour individualized fluid management aimed at maintaining euvolaemia while avoiding unne
Electrolyte abnormalities, particularly hypokalaemia, hypomagnesaemia, hypophosphataemia, and hyponatraemia, should be identified and corrected because they may impair gastrointestinal motility, neuromuscular function, and metabolic recovery. Patients with prolonged inadequate intake or severe malnutrition require particular vigilance for refeeding syndrome during nutritional rehabilitation, including appropriate monitoring and replacement of phosphate, potassium, magnesium, and thiamine[72]. Appropriate fluid and electrolyte management therefore provides the physio
Nutritional rehabilitation requires repeated assessment because nutritional requirements and tolerance frequently change during postoperative recovery. Monitoring should include oral intake, delivery of prescribed enteral or PN, achievement of protein and energy targets, gastrointestinal tolerance, body weight, fluid balance, bowel function, and relevant bio
Patients with prolonged ileus, anastomotic complications, pancreatic fistulae, high-output stomas, severe infection, or other causes of intestinal dysfunction require particularly close surveillance because nutritional requirements may increase while delivery becomes more difficult[73]. Body composition and functional measures, including muscle strength and physical performance, may provide additional information regarding recovery beyond conventional anthropometric measures[74].
Regular multidisciplinary review allows nutritional therapy to be escalated or de-escalated according to the patient's evolving clinical condition. Importantly, nutritional monitoring should not end at hospital discharge. Patients with persistent nutritional deficits, upper gastrointestinal resections, pancreatic insufficiency, or ongoing adjuvant therapy require continued outpatient surveillance to maintain nutritional adequacy and functional recovery.
Hospital discharge represents a transition from inpatient recovery to continued nutritional and functional rehabilitation after gastrointestinal cancer surgery. Although ERAS pathways facilitate earlier discharge, patients may remain nutri
Structured post-discharge follow-up should therefore extend the principles of perioperative nutritional care beyond hospitalization. Its objectives are to identify evolving nutritional problems, maintain adequate energy and protein intake, manage procedure-specific gastrointestinal symptoms, support functional recovery, facilitate timely oncological treat
Nutritional compromise frequently persists despite an uncomplicated postoperative course. Anorexia, early satiety, dysphagia, delayed gastric emptying, exocrine pancreatic insufficiency, diarrhea, malabsorption, dumping syndrome, high-output stomas, and cancer-related fatigue may limit dietary intake and contribute to continued weight and muscle loss.
Patients undergoing upper gastrointestinal resections are particularly vulnerable because altered anatomy may require prolonged dietary adaptation and may result in persistent gastrointestinal symptoms. Adjuvant chemotherapy can further impair nutritional intake through nausea, vomiting, mucositis, dysgeusia, and gastrointestinal toxicity. Without continued surveillance, these factors may contribute to progressive malnutrition, sarcopenia, functional decline, treat
Post-discharge nutritional assessment should therefore be individualized and should include dietary intake, weight trajectory, gastrointestinal symptoms, hydration, functional status, and adherence to prescribed nutritional support. Early identification of deterioration permits timely dietary intervention, escalation of nutritional support, or investigation of procedure-specific complications.
Unplanned readmission within 30 days after gastrointestinal cancer surgery may result from dehydration, inadequate oral intake, nutritional deterioration, gastrointestinal dysfunction, postoperative infection, or complications related to gastrointestinal reconstruction. Nutritional and transitional care should therefore focus on potentially modifiable factors contributing to these events. Importantly, evidence linking individual nutritional interventions directly to reduced readmission remains less robust than evidence for intermediate outcomes such as nutritional adequacy, weight mainte
Continuation of ONSs after discharge can improve energy and protein intake and help preserve nutritional status in patients unable to meet requirements through diet alone. Patients with persistent nutritional risk, upper gastrointestinal resections, or ongoing adjuvant therapy may require supplementation for several weeks or months, according to indi
Regular dietitian follow-up provides an opportunity for individualized dietary counselling, assessment of nutritional adequacy, adjustment of oral, enteral, or parenteral support, and management of procedure-specific gastrointestinal symptoms. Education regarding meal planning, protein intake, hydration, micronutrient supplementation, and appro
Telephone-based or other remote follow-up can complement face-to-face assessment during the early post-discharge period. Monitoring dietary intake, hydration, gastrointestinal tolerance, bowel function, weight trajectory, and adherence to nutritional recommendations may facilitate earlier recognition of deterioration and timely outpatient intervention[77]. Although such strategies are promising, their ability to independently prevent readmission remains an area requiring further prospective evaluation.
Comprehensive transitional-care programmes integrate nutritional support with rehabilitation, oncology follow-up, discharge planning, and community healthcare services. Such coordinated approaches may improve continuity of care, support functional recovery, facilitate timely initiation of adjuvant therapy, and reduce potentially avoidable healthcare utilization. Their effectiveness is likely to depend on patient selection, intensity of follow-up, multidisciplinary coordina
Digital health technologies are increasingly being incorporated into postoperative nutritional and transitional care. Telemedicine can provide continuing access to surgeons, dietitians, oncologists, physiotherapists, and specialist nurses, particularly for patients requiring prolonged follow-up or those with limited access to specialist services. Remote assess
Mobile health applications can complement clinical follow-up through dietary and symptom tracking, hydration logs, medication reminders, exercise guidance, educational resources, and collection of patient-reported outcomes. These tools may improve patient engagement and facilitate communication between patients and multidisciplinary teams.
Emerging applications of artificial intelligence and predictive analytics may further enable identification of patients at increased risk of nutritional deterioration, delayed recovery, postoperative complications, or readmission. However, these applications remain an evolving field, and their clinical effectiveness, generalizability, cost-effectiveness, and integration into routine perioperative pathways require prospective validation.
Digital health should therefore be viewed as an adjunct rather than a replacement for conventional clinical and nutritional assessment. Its greatest potential may lie in integrating remote monitoring with predefined clinical thresholds and multidisciplinary intervention, thereby strengthening continuity of nutritional care during the vulnerable post-discharge period[78].
The principles of perioperative nutritional care are broadly applicable across gastrointestinal oncology surgery; however, the anatomical and physiological consequences of individual procedures create distinct nutritional challenges. Diffe
Patients undergoing esophagectomy are among the groups at greatest nutritional risk because preoperative dysphagia, odynophagia, and tumor-related obstruction may result in substantial weight loss, reduced oral intake, and sarcopenia. Following surgery, delayed gastric emptying, altered gastrointestinal anatomy, anastomotic complications, recurrent laryngeal nerve dysfunction, and aspiration risk may further limit oral intake.
Temporary EN through a nasojejunal tube or feeding jejunostomy may be required when adequate oral intake cannot be established promptly. Oral feeding should be advanced according to gastrointestinal tolerance and clinical status. Longer-term management includes small, frequent, energy- and protein-dense meals, adequate hydration, and manage
Evidence level: Moderate evidence. Procedure-specific nutritional requirements are supported by clinical guidelines, observational studies, and perioperative studies, although optimal long-term nutritional strategies after esophagectomy remain incompletely defined.
Gastrectomy alters gastric reservoir capacity and gastrointestinal physiology and may result in early satiety, reduced meal tolerance, dumping syndrome, bile reflux, and progressive micronutrient deficiencies. The extent of nutritional consequences varies according to whether the resection is partial or total.
Postoperative nutritional management includes gradual advancement of oral intake, small and frequent meals, adequate protein and energy intake, and oral nutritional supplementation when dietary intake is insufficient. Patients with dumping syndrome may benefit from individualized dietary modification, including avoidance of large quantities of rapidly absorbable carbohydrates. Long-term surveillance for vitamin B12, iron, calcium, folate, and vitamin D defi
Evidence level: Moderate evidence. The need for nutritional surveillance and micronutrient replacement is well established, whereas the optimal composition and duration of supplementation vary between patients.
Nutritional recovery following colorectal surgery is generally faster than after major upper gastrointestinal procedures, and early oral feeding is feasible in most patients within ERAS pathways. Nutritional management should nevertheless account for postoperative bowel dysfunction, anastomotic complications, and the presence of a diverting or permanent stoma.
Patients with ileostomies require particular attention to fluid and sodium losses because high-output stomas can result in dehydration, electrolyte abnormalities, acute kidney injury, and repeated hospital presentations. Nutritional coun
Evidence level: Moderate evidence. Evidence supporting early oral feeding within ERAS is strong, whereas evidence specifically linking individualized stoma-related nutritional interventions to prevention of readmission is more limited.
Pancreaticoduodenectomy presents distinctive nutritional challenges because of delayed gastric emptying, pancreatic exocrine insufficiency, altered gastrointestinal anatomy, and increased metabolic requirements during recovery. Oral intake should generally be advanced according to gastrointestinal tolerance, while enteral nutritional support may be considered in selected patients who cannot achieve adequate oral intake.
Long-term nutritional management should include active assessment for pancreatic exocrine insufficiency, with pancreatic enzyme replacement therapy when clinically indicated. Dietary management should be individualized rather than based on routine fat restriction, and patients should be assessed for weight loss, steatorrhoea, malabsorption, glucose intolerance or diabetes, and micronutrient deficiencies. Fat-soluble vitamin supplementation may be required in patients with clinically significant malabsorption[82].
Evidence level: Moderate evidence. Evidence supports early recognition and treatment of nutritional and pancreatic insufficiency, although procedure-specific evidence defining optimal nutritional regimens remains heterogeneous.
Patients undergoing hepatic resection generally have fewer long-term anatomical limitations to oral intake than those undergoing esophageal or gastric resection. Nevertheless, major hepatectomy is associated with substantial metabolic stress, increased protein turnover, and transient changes in hepatic synthetic function. Nutritional management should therefore focus on maintaining adequate energy and protein intake while avoiding unnecessary dietary restrictions.
Oral feeding can generally be resumed early according to tolerance. Patients with underlying chronic liver disease require individualized assessment of fluid, electrolyte, and nutritional requirements. Routine protein restriction should generally be avoided unless specifically indicated by the clinical context. Preservation of skeletal muscle is particularly important because sarcopenia has been associated with increased postoperative morbidity and poorer outcomes fo
Evidence level: Moderate evidence. The importance of maintaining nutritional and functional reserve is supported by observational and prognostic studies, whereas the optimal procedure-specific nutritional intervention requires further prospective evaluation.
Procedure-specific nutritional management should not be viewed as an alternative to standardized ERAS care but as an extension of it. Core principles - including nutritional screening, early oral or enteral feeding, individualized nutritional support, early mobilization, symptom control, and continued post-discharge surveillance - apply across gastrointestinal oncology surgery. The intensity and composition of nutritional intervention should then be modified according to the anatomical and functional consequences of the specific procedure.
This approach is particularly relevant when considering readmission risk. Nutritional deterioration, dehydration, gastrointestinal dysfunction, and treatment-related toxicity may present differently after esophagectomy, gastrectomy, colorectal surgery, pancreaticoduodenectomy, and hepatic resection. Consequently, post-discharge surveillance should incorporate procedure-specific warning signs and predefined pathways for nutritional intervention rather than relying on a uniform follow-up strategy.
The available literature demonstrates that the evidence base is not uniform across perioperative nutritional interventions. Established components of ERAS, including routine nutritional screening, early oral or enteral feeding, individualized fluid management, and multidisciplinary perioperative care, are supported by relatively strong evidence. In contrast, procedure-specific nutritional strategies, immunonutrition, post-discharge dietitian-led interventions, digital health, precision nutrition, and artificial intelligence remain supported by more heterogeneous evidence. Importantly, evidence for improvement in nutritional status, postoperative complications, or length of stay should not automatically be inter
The principal clinical implication is that nutritional care should be individualized while remaining embedded within a standardized ERAS pathway. Patients with severe nutritional risk, sarcopenia, persistent inadequate intake, or proce
| Recommendation | Evidence grade | Principal supporting evidence |
| Routine nutritional screening | High-quality evidence | ESPEN and ERAS guidelines; multiple observational studies and validated screening studies |
| Oral nutritional supplements in patients unable to meet requirements orally | High-quality evidence | ESPEN recommendations; randomized and comparative studies |
| Early oral feeding after gastrointestinal surgery | High-quality evidence | Randomized controlled trials; systematic reviews and meta-analyses |
| Enteral nutrition when oral intake is inadequate and the gastrointestinal tract is functional | High-quality evidence | Randomized trials; systematic reviews/meta-analyses; international guidelines |
| Preoperative parenteral nutrition in selected severely malnourished patients | Moderate-quality evidence | ESPEN recommendations; randomized and comparative studies |
| Immunonutrition in selected high-risk/major gastrointestinal surgery | Moderate-quality evidence | Randomized controlled trials; systematic reviews/meta-analyses; guideline recommendations |
| Multimodal prehabilitation | Moderate-quality evidence | Randomized controlled trials; systematic reviews and meta-analyses |
| Goal-directed fluid therapy | Moderate-to-high-quality evidence | Randomized trials; systematic reviews/meta-analyses; ERAS recommendations |
| Multidisciplinary ERAS care | High-quality evidence | ERAS implementation studies; prospective cohorts; systematic reviews |
| Procedure-specific nutritional pathways | Moderate-quality evidence | Procedure-specific guidelines, cohort studies, and comparative studies |
| Post-discharge dietitian-led nutritional follow-up | Moderate-quality evidence | Cohort and intervention studies; clinical guidelines |
| Structured transitional care for prevention of readmission | Moderate-quality evidence | Transitional-care studies; observational and comparative evidence |
| Telemedicine and digital nutritional monitoring | Emerging evidence | Pilot studies; observational studies; early comparative studies |
| AI-assisted nutritional/body-composition assessment | Emerging evidence | Early validation and retrospective/observational studies |
| Precision nutrition based on body composition, metabolic, inflammatory, or microbiome characteristics | Emerging evidence | Translational, observational, and early clinical research |
Despite substantial evidence supporting perioperative nutritional care and ERAS pathways, implementation remains inconsistent across healthcare systems. The principal challenge is not the absence of effective interventions but the reliable delivery of multiple interdependent components within routine clinical workflows. Successful implementation requires standardized protocols, multidisciplinary ownership, adequate resources, patient engagement, and continuous measure
Implementation barriers can be usefully conceptualized using the Consolidated Framework for Implementation Research, which categorizes determinants across intervention characteristics, outer setting, inner setting, characteristics of individuals, and implementation process. This framework is particularly relevant to ERAS because these pathways represent complex, multidisciplinary interventions whose effectiveness depends on adaptation to local organizational and patient contexts[85].
Intervention characteristics include the complexity of ERAS pathways, the number of nutritional and perioperative components, and the need to adapt recommendations to different gastrointestinal procedures. Protocols that are exce
Outer-setting factors include healthcare policies, availability of nutritional products and rehabilitation services, financial incentives, referral pathways, and patient needs and resources. These factors are particularly important in low- and middle-income settings, where limited access to specialist dietitians, physiotherapists, nutrition-support teams, immunonutrition products, and structured outpatient services may constrain implementation[86].
Inner-setting factors include staffing, institutional culture, leadership engagement, communication systems, availability of resources, and compatibility of ERAS processes with existing clinical workflows. Inconsistent communication between surgeons, anesthesiologists, nurses, dietitians, physiotherapists, and oncologists can lead to fragmented nutritional care. Conversely, strong multidisciplinary communication, visible leadership support, and integration of ERAS processes into routine documentation and ward workflows facilitate implementation[85,86].
Characteristics of individuals include clinicians' knowledge, beliefs, confidence, and perceived value of ERAS and nutritional interventions. Resistance to changing established fasting, feeding, analgesic, or mobilization practices may persist despite guideline recommendations. Education, multidisciplinary training, local clinical champions, and feedback on patient outcomes can improve professional engagement and reinforce adherence.
Implementation processes require deliberate planning rather than passive dissemination of guidelines. Practical strategies include appointment of an ERAS or nutrition coordinator, multidisciplinary education, standardized order sets and checklists, identification of procedure-specific nutritional targets, and prospective audit with regular feedback. Audit systems should monitor both process measures - such as nutritional screening, early feeding, achievement of protein and energy targets, mobilization, and protocol adherence - and clinical outcomes including complications, length of stay, readmissions, and patient-reported outcomes. Experience from ERAS implementation programmes indicates that continuous feedback, multidisciplinary ownership, local adaptation, and dedicated coordination can overcome important organizational barriers[85].
Patient engagement represents an additional implementation determinant. Adherence to ONSs, dietary recommendations, physical activity, hydration, and postoperative rehabilitation is influenced by health literacy, treatment-related symptoms, socioeconomic circumstances, and family support. Individualized education, shared decision-making, written and digital instructions, and involvement of caregivers can improve participation in the recovery pathway.
Implementation should therefore be viewed as a continuous quality-improvement process rather than a one-time protocol adoption. A practical model is to establish a multidisciplinary implementation team, map the existing perioperative pathway, identify local barriers using Consolidated Framework for Implementation Research domains, introduce a standardized but adaptable ERAS-nutrition pathway, assign defined responsibilities to team members, and conduct regular audit-and-feedback cycles. Such an approach allows institutions to identify gaps in care and iteratively modify processes according to local needs.
This framework is particularly important in resource-constrained environments, where implementation strategies must prioritize high-value interventions and make efficient use of existing personnel and infrastructure. Evidence from low- and lower-middle-income settings demonstrates that adaptation of established pathways, formal implementation lea
Perioperative nutritional care in gastrointestinal oncology is increasingly moving from standardized supportive protocols toward individualized, longitudinal, and technology-enabled care. ERAS provides the foundational framework, but future strategies will increasingly integrate nutritional phenotype, body composition, functional capacity, treatment trajectory, and patient-generated data to determine the intensity and duration of nutritional intervention.
Precision nutrition represents an emerging approach in which nutritional strategies are tailored according to body composition, metabolic status, inflammatory profile, tumor characteristics, treatment-related factors, and potentially the gut microbiome. Such approaches may allow more accurate estimation of energy and protein requirements and identification of patients most likely to benefit from specific nutritional interventions. However, these concepts remain predominantly investigational, and their clinical utility requires prospective validation.
Prehabilitation is another important area of development. Contemporary evidence suggests that exercise-based prehabilitation can improve preoperative and postoperative functional capacity in patients undergoing gastrointestinal cancer surgery, although effects on complications, readmission, and survival remain less certain. Recent meta-analyses support improvement in functional capacity while emphasizing heterogeneity in intervention type, duration, and patient selection[88]. Future trials should therefore evaluate integrated programmes combining exercise, nutritional optimization, psychological support, and procedure-specific conditioning rather than considering these interventions independently.
The role of immunonutrition is also being refined. Recent systematic reviews and meta-analyses continue to demon
Artificial intelligence may facilitate objective nutritional risk stratification by integrating demographic characteristics, laboratory parameters, clinical data, functional measures, and imaging. Automated analysis of routine staging computed tomography scans may permit scalable identification of sarcopenia, myosteatosis, and visceral adiposity without re
Digital health and remote monitoring may extend nutritional and functional surveillance beyond hospital discharge. Telemedicine, mobile applications, wearable devices, and patient-reported outcome platforms can facilitate monitoring of dietary intake, weight, hydration, gastrointestinal symptoms, physical activity, and treatment-related toxicity. Recent evidence in oncology suggests that remote patient monitoring can improve symptom-related outcomes and quality of life, particularly when integrated with active clinical follow-up and nursing support[90]. Nevertheless, evidence specifically addressing postoperative nutritional outcomes and readmission prevention after gastrointestinal cancer surgery remains limited, and procedure-specific prospective trials are required.
Future digital platforms may integrate nutritional data with ERAS milestones, laboratory values, body composition, patient-reported symptoms, and functional measures to generate individualized alerts. Such systems could support risk-adapted transitional care, allowing high-risk patients to receive more intensive dietetic, rehabilitative, and oncological follow-up while lower-risk patients undergo less intensive surveillance.
Several important evidence gaps remain. Future RCTs should determine the optimal timing, duration, composition, and route of perioperative nutritional interventions across individual gastrointestinal procedures. Research should also establish procedure-specific protein and energy targets, clarify the clinical significance of changes in skeletal muscle mass and quality, and determine whether nutritional optimization translates into improved tolerance and completion of adjuvant therapy and better long-term oncological outcomes.
Studies evaluating digital health interventions should incorporate standardized clinical endpoints, including nutri
This review has several limitations. First, its narrative design did not involve a formal systematic-review protocol, duplicate study selection, or quantitative meta-analysis, and selective citation cannot be entirely excluded. Second, the search was restricted to English-language publications, which may have resulted in language and publication bias. Third, substantial heterogeneity exists across gastrointestinal malignancies, surgical procedures, nutritional interventions, ERAS pathways, patient risk profiles, and reported outcomes, limiting direct comparison between studies. Fourth, much of the evidence supporting perioperative nutritional care concerns intermediate outcomes, including postoperative complications, length of stay, nutritional adequacy, and functional recovery, rather than 30-day readmission as a primary endpoint. Evidence that nutritional or transitional interventions independently reduce readmissions remains limited and may be confounded by overall pathway adherence, discharge planning, comorbidity, and institutional practice. Finally, the evidence categories used in this review represent a pragmatic narrative appraisal and should not be interpreted as a formal GRADE assessment. These limitations support the need for procedure-specific randomized studies using stan
Perioperative nutritional care should extend from preoperative assessment through post-discharge follow-up and be incorporated into multidisciplinary ERAS pathways. Current evidence supports nutritional screening, individualized nutritional therapy, early oral or enteral feeding, prehabilitation, and coordinated postoperative care to improve nutri
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