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Practice Guideline
. 2025 Oct:53:222-261.
doi: 10.1016/j.clnu.2025.08.029. Epub 2025 Sep 3.

ESPEN guideline on clinical nutrition in surgery - Update 2025

Arved Weimann  1 , Mihailo Bezmarevic  2 , Marco Braga  3 , M Isabel T D Correia  4 , Pamela Funk-Debleds  5 , Luca Gianotti  6 , Chelsia Gillis  7 , Martin Hübner  8 , Jesus Fernando B Inciong  9 , Mohammad Shukri Jahit  10 , Stanislaw Klek  11 , Takayuki Kori  12 , Alessandro Laviano  13 , Olle Ljungqvist  14 , Dileep N Lobo  15 , Carmelo Loinaz Segurola  16 , Isacco Montroni  17 , B Ravinder Reddy  18 , Nicole M Saur  19 , Anna Schweinlin  20 , Han-Ping Shi  21 , Hiroya Takeuchi  22 , Dan L Waitzberg  23 , Ola Wallengren  24 , Paul E Wischmeyer  25 , Dirk Ysebaert  26 , Stephan C Bischoff  20
Affiliations
Practice Guideline

ESPEN guideline on clinical nutrition in surgery - Update 2025

Arved Weimann et al. Clin Nutr. 2025 Oct.

Abstract

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, nutritional therapy is mandatory for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include: a) Integration of nutrition into the overall management of the patient, b) avoidance of long periods of preoperative fasting c) re-establishment of oral feeding as early as possible after surgery d) start of nutritional therapy early, as soon as a nutritional risk becomes apparent e) metabolic control e.g. of blood glucose, f) reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function, g) minimized time on paralytic agents in the postoperative period, and h) early mobilization to facilitate protein synthesis and muscle function. The guideline presents 44 recommendations for clinical practice in patients undergoing elective and non-elective surgery, including new recommendations for frailty assessment, sarcopenia diagnosis, and prehabilitation. As in the former ESPEN practical guideline, the recommendations were additonally presented in decision-making flowcharts.

Keywords: Enhanced recovery after surgery; Enteral nutrition; Parenteral nutrition; Perioperative nutrition; Prehabilitation; Surgery.

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Conflict of interest statement

Conflict of interest The expert members of the working group were accredited by the ESPEN Guidelines Group, the ESPEN Education and Clinical Practice Committee, and the ESPEN executive. All expert members have declared their individual conflicts of interest according to the rules of the International Committee of Medical Journal Editors (ICMJE). If potential conflicts were indicated, they were reviewed by the ESPEN guideline officers and, in cases of doubts, by the ESPEN executive. AW: grants from B. Braun and Seca. consulting fees from Longevist Science for Life GmbH, payment or honoraria for lectures etc. from Abbott, Baxter Deutschland GmbH, B. Braun Melsungen AG, Falk Foundation, Fresenius Kabi Deutschlang GmbH; MB: chairman of National Society for Clinical Nutrition – Serbia (NUPENS); MB: payment or honoraria for lectures etc. from Health&Life Company, Honorarium for lecture on enoxaparin in high-risk patients with enhanced recovery program; MITDC: grants from Abbott Nutrition, Fresenius Nutrition, Nestlé Nutrition, consulting fees from Abbott Nutrition, Fresenius Nutrition, payment or honoraria for lectures etc. from Abbott Nutrition, Fresenius Nutrition, Nestlé Nutrition, President of the Brazilian Society of Parenteral and Enteral Nutrition; PFD: consulting fees from B. Braun, Baxter, BMS, Nestlé Health Science, Nutricia, Fresenius Kabi, Theradial, Viatris; LG: payment or honoraria for lectures etc. from Baxter, support for attending meetings from Akern SpA, President of the Society ERAS-Italia; CG: payment or honoraria for lectures from Abbott Nutrition, Nestlé, Fresenius Kabi; MH: leadership or fiduciary role at the international society of pleura & peritoneum; JFBI: payment or honoraria for lectures etc. from Nestlé, Abbott, Fresenius Kabi, support for attending meetings from Nestlé, Abbott, Fresenius Kabi; MSH: payment or honoraria for lectures etc. from Fresenius Kabi, Abbott, Baxter; SK: payment or honoraria for lectures etc. from Baxter, B. Braun, Nutricia, Fresenius Kabi, Nestlé, ESPEN chairman, Associate Editor of Clinical Nutrition; TK: nothing to declare; AL: consulting fees from Abbott, Baxter, B. Braun, Fresenius Kabi, Nestlé Health Sciences, Nutricia, payment or honoraria for lectures etc. from Abbott, B. Braun, Fresenius Kabi, Nutricia; data safety monitoring/advisory board member of Danone Oncology, Associate Editor of Clinical Nutrition; OL: payment or honoraria for lectures etc. from Encare AB, ERAS Society Executive Board, Stock owner Encare AB; DNL: Editor in Chief of Clinical Nutrition, Associate Editor of the World Journal of Surgery; CLS: payment or honoraria for lectures etc. from Abbott, Ethicon, support for attending meetings from Takeda, Chiesi; IM: payment or honoraria for lectures etc. from Olympus SE, Fresenius Kabi, International Society of Geriatric Oncology Board Member; BRR: Panel Member of World Health Organisation (WHO) on Nutritional Recommendations for Hospitalised Patients in South-East Asian Region; NMS: Royalties for UpToDate; AS: nothing to declare; HS: nothing to declare; HT: nothing to declare; DLW: grants from Nestlé Health Science, Baxter, consulting fees from Sanofi, payment or honoraria for lectures etc. from Farmoquimica, Baxter, Nestlé Healt Science, support for attending meetings from Sanofi, Advisory Board member of Biocodex, recipient of medical writing from Nestlé Health Science and Fresenius Kabi, Associate Editor of Clinical Nutrition; OW: payment or honoraria for lectures etc. from Fresenius Kabi, support for attending meetings from Assar Gabrielssons fond, The Local Research and Development Council Gothenburg and Södra Bohuslän, board member of SWESPEN and the Swedish Association for Clinical Nutrition (SFKN); PEW: grants from Abbott, Baxter, Fresenius Kabi; consulting fees from Abbott, Baxter, Fresenius Kabi, Nutricia, DSM, Mend Inc., ART Medical; Payment or honoraria for lectures etc. from Abbott, Baxter, Fresenius Kabi, Nutricia, DSM, Nestle; support for attending meetings from Abbott, Baxter, Fresenius, Nutricia, DSMB chair for NIH Mending trial for delirium prevention with pharmacology agent, Stock options (unvalued) in Musclesound, Unrestricted gift funding from DSM, Musclesound for research, Unrestricted education funding grant from Abbott, Associate Editor of Clinical Nutrition; DY: Principal Investigator “ONCO-Care” trial: “Malnutrition prevalence in cancer patients in Belgium” supported by Fresenius Kabi, President “Belgian Society for Surgery”; SCB: grants from Heilerde-Gesellschaft Luvos Just GmbH & Co. KG, Symbiopharm GmbH, Lactopia GmbH, payment or honoraria for lectures from Falk Foundation, Elly Lilly, Deprom, Bayer, Takeda, Janssen, Participation on a Data, Safety Monitoring Board or Advisory Board of Nestlé Health Science and Theralution GmbH (Medice), Associate Editor of Clinical Nutrition.

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