Perioperative nutrition and multidisciplinary care in gastrointestinal oncology surgery: Evidence-based strategies to enhance recovery and inform readmission prevention

Table 1 Literature search strategy used for identification of studies included in this narrative review

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

Search terms were adapted to the indexing system of each database. Controlled vocabulary, including Medical Subject Headings in PubMed/MEDLINE and Emtree terms in EMBASE, was combined with free-text keywords using Boolean operators (AND/OR). The database search was completed on June 30, 2026; manual reference screening was completed in July 2026. ERAS: Enhanced recovery after surgery; ESPEN: European Society for Clinical Nutrition and Metabolism.

Table 2 Landmark studies on perioperative nutrition in gastrointestinal oncology surgery

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

Table 2 summarizes pivotal evidence that has influenced contemporary perioperative nutritional management in gastrointestinal surgery. The selected studies include landmark trials of immunonutrition and early feeding together with current guideline-based recommendations. Effect estimates are reported as provided in the cited studies; they should be interpreted in the context of differences in patient selection, surgical procedures, nutritional protocols, and outcome definitions. ERAS: Enhanced recovery after surgery; RCT: Randomized controlled trial; ω-3: Omega-3 fatty acids; ESPEN: European Society for Clinical Nutrition and Metabolism.

Table 3 Narrative grading of the strength of evidence supporting major perioperative nutritional interventions in gastrointestinal oncology surgery

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

Evidence was graded narratively according to the hierarchy, quality, consistency, and clinical applicability of the available literature. High-quality evidence denotes recommendations supported by multiple randomized controlled trials, systematic reviews/meta-analyses, and/or consistent international guideline endorsement. Moderate-quality evidence denotes recommendations supported by randomized or prospective evidence that is limited in quantity, heterogeneous, procedure-specific, or supplemented primarily by observational studies. Emerging evidence denotes interventions supported mainly by preliminary clinical, observational, technological, or translational research for which clinical effectiveness remains incompletely established. Where recommendations are based predominantly on consensus or limited clinical data, they should be interpreted as expert opinion rather than formal evidence grades. This framework is descriptive and pragmatic and does not represent a formal GRADE assessment. Importantly, evidence demonstrating improvement in intermediate outcomes such as nutritional adequacy, complications, or length of stay was not assumed to constitute direct evidence of reduced 30-day readmission. ERAS: Enhanced recovery after surgery; ESPEN: European Society for Clinical Nutrition and Metabolism; AI: Artificial intelligence.