ESPEN 2025 Surgical Nutrition Guidelines Champion Early Feeding and Prehabilitation
Updated ESPEN guidelines deliver 44 evidence-based recommendations for perioperative nutrition, emphasizing early oral feeding, frailty assessment, and ERAS integration.
Summary
The 2025 ESPEN surgical nutrition guidelines update provides 44 clinical recommendations for optimizing perioperative nutritional care. Key priorities include early oral feeding after surgery, avoiding prolonged preoperative fasting, and integrating nutrition into Enhanced Recovery After Surgery (ERAS) protocols. The guidelines introduce new recommendations on frailty assessment, sarcopenia diagnosis, and prehabilitation — proactive nutritional and physical conditioning before surgery. Malnutrition and underfeeding are identified as significant risk factors for postoperative complications, making nutritional therapy mandatory for at-risk patients, particularly those undergoing upper gastrointestinal or major cancer surgery. Decision-making flowcharts accompany the recommendations to support real-world clinical application. This comprehensive, internationally authored update reflects growing evidence that metabolic optimization across the entire surgical journey meaningfully reduces complications and improves patient recovery.
Detailed Summary
Malnutrition affects a substantial proportion of surgical patients and is a well-established driver of postoperative complications, prolonged hospital stays, and increased mortality. As surgical procedures become more complex — particularly in oncology — optimizing nutritional status before, during, and after surgery has become a clinical imperative. The 2025 ESPEN guideline update on clinical nutrition in surgery addresses this need with a comprehensive, evidence-graded framework.
The guideline was developed by an international panel of experts spanning surgery, clinical nutrition, anesthesiology, and oncology. Drawing on updated evidence, the authors present 44 recommendations covering elective and non-elective surgical populations. The recommendations address the full perioperative continuum, from preoperative nutritional screening to postoperative recovery support.
Among the core findings, early oral feeding is affirmed as the preferred nutritional mode for surgical patients, with avoidance of prolonged preoperative fasting strongly recommended. The guidelines emphasize that nutritional therapy should begin as soon as nutritional risk is identified — not deferred until complications arise. Metabolic priorities include blood glucose control, minimizing stress-related catabolism, reducing paralytic agent use postoperatively, and encouraging early mobilization to support muscle protein synthesis.
Notably, the 2025 update introduces new recommendations for frailty assessment, sarcopenia diagnosis, and prehabilitation — the latter involving targeted nutritional and physical conditioning in the weeks before surgery. These additions reflect increasing recognition that preoperative functional reserve profoundly influences surgical outcomes, particularly in older and oncology patients.
The guidelines retain decision-making flowcharts to facilitate bedside application. A key caveat is that this summary is based solely on the abstract; full recommendation grading, supporting evidence levels, and nuanced clinical subgroup guidance require access to the complete publication. Additionally, several authors disclosed financial relationships with nutritional product manufacturers, which warrants consideration when interpreting specific product-related recommendations.
Key Findings
- Early oral feeding is the preferred postoperative nutritional mode; prolonged fasting should be actively avoided.
- Malnutrition and underfeeding are independent risk factors for postoperative complications requiring mandatory nutritional intervention.
- New 2025 recommendations address frailty assessment, sarcopenia diagnosis, and preoperative prehabilitation programs.
- Nutritional therapy should start as soon as nutritional risk is identified, especially in major cancer surgery patients.
- Early mobilization and minimizing postoperative paralytic agents are key to preserving muscle function and protein synthesis.
Methodology
This is an updated clinical practice guideline developed by an international ESPEN expert panel. Recommendations are based on systematic review of available evidence and graded according to standard evidence-quality frameworks. The 2025 version updates prior ESPEN surgical nutrition guidelines with new evidence and expanded clinical domains.
Study Limitations
This summary is based solely on the abstract, so specific evidence grades, subgroup nuances, and full recommendation rationale are unavailable without the complete text. Multiple guideline authors declared financial relationships with nutrition product manufacturers, which may introduce potential bias in product-specific recommendations. As a guideline rather than a primary clinical trial, the strength of individual recommendations depends on the underlying evidence base, which varies across topics.
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