ESPEN guideline: Clinical nutrition in surgery

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, early enteral feeding is especially relevant 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:• integration of nutrition into the overall management of the patient• avoidance of long periods of preoperative fasting• re-establishment of oral feeding as early as possible after surgery• start of nutritional therapy early, as soon as a nutritional risk becomes apparent• metabolic control e.g. of blood glucose• reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function• minimized time on paralytic agents for ventilator management in the postoperative period• early mobilisation to facilitate protein synthesis and muscle functionThe guideline presents 37 recommendations for clinical practice. 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, early enteral feeding is especially relevant 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: • integration of nutrition into the overall management of the patient • avoidance of long periods of preoperative fasting • re-establishment of oral feeding as early as possible after surgery • start of nutritional therapy early, as soon as a nutritional risk becomes apparent • metabolic control e.g. of blood glucose • reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function • minimized time on paralytic agents for ventilator management in the postoperative period • early mobilisation to facilitate protein synthesis and muscle function The guideline presents 37 recommendations for clinical practice. biomedical endpoints enteral nutrition (enteral tube feeding) enhanced recovery after surgery European Society for Clinical Nutrition and Metabolism health care economy endpoint integration of classical and patient-reported endpoints oral nutritional supplements parenteral nutrition quality of life tube feeding normal diet as offered by the catering system of a hospital including special diets period starting prior to surgery from hospital admission until discharge after surgery In order to make proper plans for the nutritional support of patients undergoing surgery, it is essential to understand the basic changes in metabolism that occur as a result of injury, and that a compromised nutritional status is a risk factor for postoperative complications. Starvation during metabolic stress from any type of injury differs from fasting under physiological conditions [[1]Soeters P. Bozzetti F. Cynober L. Elia M. Shenkin A. Sobotka L. Meta-analysis is not enough: the critical role of pathophysiology in determining optimal care in clinical nutrition.Clin Nutr. 2016; 35: 748-757Abstract Full Text Full Text PDF PubMed Google Scholar]. Surgery itself leads to inflammation corresponding with the extent of the surgical trauma, and leads to a metabolic stress response. To achieve appropriate healing and functional recovery (“restitutio ad integrum”) a metabolic response is necessary, but this requires nutritional therapy especially when the patient is malnourished and the stress/inflammatory response is prolonged. The negative effect of long term caloric and protein deficits on outcome for critically ill surgical patients has been shown again recently [[2]Yeh D.D. Fuentes E. QUrashi S.A. Cropano C. Kaafarani H. Lee J. et al.Adequate nutrition may get you home: effect of caloric/protein deficits on the discharge destination of critically ill surgical patients.J Parenter Enteral Nutr. 2016; 40: 37-44Crossref PubMed Scopus (9) Google Scholar]. The success of surgery does not depend exclusively on technical surgical skills, but also on metabolic interventional therapy, taking into account the ability of the patient to carry a metabolic load and to provide appropriate nutritional support. In patients with cancer, management during the perioperative period may be crucial for long-term outcome [3Horowitz M. Neeman E. Sharon E. Ben-Eliyahu S. Exploiting the critical perioperative period to improve long-term cancer outcomes.Nat Rev Clin Oncol. 2015; : 213-226Crossref PubMed Scopus (27) Google Scholar, 4Gustafsson U.O. Oppelstrup H. Thorell A. Nygren J. Ljungqvist O. Adherence to the ERAS protocol is associated with 5-year survival after colorectal cancer surgery: a retrospective cohort study.World J Surg. 2016; 40: 1741-1747Crossref PubMed Google Scholar]. Surgery, like any injury, elicits a series of reactions including release of stress hormones and inflammatory mediators, i.e. cytokines. The cytokine response to infection and injury, the so-called “Systemic Inflammatory Response Syndrome”, has a major impact on metabolism. The syndrome causes catabolism of glycogen, fat and protein with release of glucose, free fatty acids and amino acids into the circulation, so that substrates are diverted from their normal purpose of maintaining peripheral protein (especially muscle) mass, to the tasks of healing and immune response [5Gillis C. Carli F. Promoting perioperative metabolic and nutritional care.Anesthesiology. 2015; 123: 1455-1472Crossref PubMed Google Scholar, 6Alazawi W. Pirmadid N. Lahiri R. Bhattacharya S. Inflammatory and immune responses to surgery and their clinical impact.Ann Surg. 2016; 64: 73-80Crossref Scopus (1) Google Scholar]. The consequence of protein catabolism is the loss of muscle tissue which is a short and long-term burden for functional recovery which is considered the most important target [[7]Aahlin E.K. Tranø G. Johns N. Horn A. Søreide J.A. Fearon K.C. et al.Risk factors, complications and survival after upper abdominal surgery: a prospective cohort study.BMC Surg. 2015; 15: 83Crossref PubMed Scopus (5) Google Scholar]. In order to spare protein stores, lipolysis, lipid oxidation, and decreased glucose oxidation are important survival mechanisms [[8]Soeters M.R. Soeters P.B. Schooneman M.G. Houten S.M. Rimijn J.A. Adaptive reciprocity of lipid and glucose metabolism in human short-term starvation.Am J Physiol Endocrinol Metab. 2012; 303: E1397-E1407Crossref PubMed Scopus (21) Google Scholar]. Nutritional therapy may provide the energy for optimal healing and recovery, but in the immediate postoperative phase may only minimally counteract muscle catabolism, or not at all. To restore peripheral protein mass the body needs to deal with the surgical trauma and possible infection adequately. Nutritional support/intake and physical exercise are prerequisites to rebuild peripheral protein mass/body cell mass. Patients undergoing surgery may suffer from chronic low-grade inflammation as in cancer, diabetes, renal and hepatic failure [[9]Soeters P.B. Schols A.M. Advances in understanding and assessing malnutrition.Curr Opin Clin Nutr Metab Care. 2009; 12: 487-494Crossref PubMed Scopus (0) Google Scholar]. Other non-nutritional metabolic factors interfering with an adequate immune response have to be taken into account and, whenever possible, corrected or ameliorated before surgery. These are diminished cardio-respiratory organ function, anaemia, acute and chronic intoxications (e.g. alcohol, recreational drugs), medical treatment with anti-inflammatory and cytotoxic drugs. The surgeon has to balance the extent of surgery according to nutritional state, inflammatory activity and anticipated host response. Severe pre-existing inflammation and sepsis influence healing negatively (wounds, anastomoses, immune function, etc.) but also decrease the benefit of nutritional therapy. Severely malnourished patients may exhibit an adynamic form of sepsis with hypothermia, leukopenia, somnolence, impaired wound healing and pus production, altogether leading to slow deterioration and mortality. In this situation nutritional therapy will not maintain or build up muscle mass but may restore an adequate stress response, promoting the chances of recovery. Awareness for the impaired inflammatory stress response means limiting the extent of the surgical trauma and may lead to uneventful recovery. Severely compromised patients should receive perioperative nutritional therapy of longer duration or when acute intervention is required, surgery should be limited or minimally invasive interventional techniques should be preferred to relieve infection/ischaemia. In order to optimize the mildly malnourished patient short-term (7–10 days) nutritional conditioning has to be considered. In severely malnourished patients longer periods of nutritional conditioning are necessary and this should be combined with resistance exercise. In the truly infected patient immediately dealing with the focus of sepsis (“source control”) should have priority and no major surgery should be performed (risky anastomoses, extensive dissections etc.). Definitive surgery should be performed at a later stage when sepsis has been treated adequately. In elective surgery it has been shown that measures to reduce the stress of surgery can minimize catabolism and support anabolism throughout surgical treatment and allow patients to recover substantially better and faster, even after major surgical operations. Such programmes for Fast Track surgery [[10]Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation.Br J Anaesth. 1997; 78: 606-617Crossref PubMed Google Scholar] later developed into Enhanced Recovery after Surgery (ERAS). A series of components that combine to minimize stress and to facilitate the return of function have been described: these include preoperative preparation and medication, fluid balance, anaesthesia and postoperative analgesia, pre- and postoperative nutrition, and mobilization [5Gillis C. Carli F. Promoting perioperative metabolic and nutritional care.Anesthesiology. 2015; 123: 1455-1472Crossref PubMed Google Scholar, 11Fearon K.C. Ljungqvist O. Von Meyenfeldt M. Revhaug A. Dejong C.H. Lassen K. et al.Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection.Clin Nutr. 2005; 24: 466-477Abstract Full Text Full Text PDF PubMed Scopus (533) Google Scholar, 12Ljungqvist O. ERAS-enhanced recovery after surgery: moving evidence-based perioperative care to practice.J Parenter Enteral Nutr. 2014; 38: 559-566Crossref PubMed Scopus (0) Google Scholar, 13Bakker N. Cakir H. Doodeman H.J. Houdijk A.P. Eight years of experience with Enhanced Recovery After Surgery in patients with colon cancer: impact of measures to improve adherence.Surgery. 2015; 157: 1130-1136Abstract Full Text Full Text PDF PubMed Google Scholar]. The ERAS programmes have now become a standard in perioperative management that has been adopted in many countries across several surgical specialties. They were developed in colonic operations [11Fearon K.C. Ljungqvist O. Von Meyenfeldt M. Revhaug A. Dejong C.H. Lassen K. et al.Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection.Clin Nutr. 2005; 24: 466-477Abstract Full Text Full Text PDF PubMed Scopus (533) Google Scholar, 14Lassen K. Soop M. Nygren J. Cox P.B. Hendry P.O. Spies C. et al.Enhanced Recovery After Surgery (ERAS) GroupConsensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations.Arch Surg. 2009; 144: 961-969Crossref PubMed Scopus (413) Google Scholar, 15Varadhan K.K. Neal K.R. Dejong C.H. Fearon K.C. Ljungqvist O. Lobo D.N. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials.Clin Nutr. 2010; 29: 434-440Abstract Full Text Full Text PDF PubMed Scopus (366) Google Scholar, 16Greco M. Capretti G. Beretta L. Gemma M. Pecorelli N. Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials.World J Surg. 2014; 38: 1531-1541Crossref PubMed Scopus (85) Google Scholar, 17Gustafsson U.O. Scott M.J. Schwenk W. Demartines N. Roulin D. Francis N. Enhanced Recovery After Surgery Society et al.Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations.Clin Nutr. 2012; 31: 783-800Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar] and are now being applied to all major operations. ERAS programmes have been also successful in promoting rapid “functional” recovery after gastrectomy [[18]Mortensen K. Nilsson M. Slim K. Schäfer M. Mariette C. Braga M. et al.Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations.Br J Surg. 2014; 101: 1209-1229Crossref PubMed Scopus (0) Google Scholar], pancreatic resections [19Balzano G. Zerbi A. Braga M. Rocchetti S. Beneduce A.A. Di Carlo V. Fast-track recovery programme after pancreatico-duodenectomy reduces delayed gastric emptying.Br J Surg. 2008; 95: 1387-1393Crossref PubMed Scopus (132) Google Scholar, 20Braga M. Pecorelli N. Ariotti R. Capretti G. Greco M. Balzano G. et al.Enhanced recovery after surgery pathway in patients undergoing pancreaticoduodenectomy.World J Surg. 2014; 38: 2960-2966Crossref PubMed Scopus (11) Google Scholar], pelvic surgery [21Nygren J. Thacker J. Carli F. Fearon K.C. Norderval S. Lobo D.N. Enhanced Recovery After Surgery Society et al.Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations.Clin Nutr. 2012; 31: 801-816Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 22Patel H.R. Cerantola Y. Valerio M. Persson B. Jichlinski P. Ljungqvist O. et al.Enhanced recovery after surgery: are we ready, and can we afford not to implement these pathways for patients undergoing radical cystectomy?.Eur Urol. 2014; 65: 263-266Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar], hysterectomy [[23]Wijk L. Franzen K. Ljungqvist O. Nilsson K. Implementing a structured Enhanced Recovery after Surgery (ERAS) protocol reduces length of stay after abdominal hysterectomy.Acta Obstet Gynecol Scand. 2014; 93: 749-756Crossref PubMed Scopus (18) Google Scholar], gynaecologic oncology [[24]Nelson G. Altman A.D. Nick A. Meyer L.A. Ramirez P.T. Achtari C. et al.Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations – part 1.Gynecol Oncol. 2016; 140: 313-322Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar]. In times of limitations in health care economy ERAS is also a reasonable contribution for the purpose of saving resources [[25]Bond Smith G. Belgaumkar A.P. Davison B.R. Gurusamy K.S. Enhanced recovery protocols for major upper gastrointestinal, liver and pancreatic surgery.Cochrane Database Syst Rev. 2016; 1 (CD011382): 2Google Scholar]. ERAS protocols have been also shown to be safe and beneficial in the elderly [[26]Slieker J. Frauche P. Jurt J. Addor V. Blanc C. Demartines N. et al.Enhanced recovery ERAS for elderly: a safe and beneficial pathway in colorectal surgery.Int J Colorectal Dis. 2017; 32: 215-221Crossref PubMed Scopus (0) Google Scholar]. High adherence to ERAS protocols may be associated with improved 5-year cancer specific survival after major colorectal surgery [[4]Gustafsson U.O. Oppelstrup H. Thorell A. Nygren J. Ljungqvist O. Adherence to the ERAS protocol is associated with 5-year survival after colorectal cancer surgery: a retrospective cohort study.World J Surg. 2016; 40: 1741-1747Crossref PubMed Google Scholar]. As a key component of ERAS, nutritional management is an inter-professional challenge. The ERAS programmes also include a metabolic strategy to reduce perioperative stress and improve outcomes [[12]Ljungqvist O. ERAS-enhanced recovery after surgery: moving evidence-based perioperative care to practice.J Parenter Enteral Nutr. 2014; 38: 559-566Crossref PubMed Scopus (0) Google Scholar]. While early oral feeding is the preferred mode of nutrition, avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Keeping in mind that the nutritional status is a risk factor for postoperative complications, this is especially relevant for patients at nutritional risk and those undergoing upper gastrointestinal (GI) surgery. For this reason, ERAS guidelines recommend liberal subscription of oral supplements pre- and postoperatively. Equally ERAS protocols support early oral intake for the return of gut function. From a metabolic and nutritional point of view, the key aspects of perioperative care include:•integration of nutrition into the overall management of the patient•avoidance of long periods of preoperative fasting•re-establishment of oral feeding as early as possible after surgery•start of nutritional therapy early, as soon as a nutritional risk becomes apparent•metabolic control e.g. of blood glucose•reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function•minimize time on paralytic agents for ventilator management in the postoperative period•early mobilisation to facilitate protein synthesis and muscle function. Nutrition therapy. Synonym: nutritional support is defined according to the European Society for Clinical Nutrition and Metabolism (ESPEN) [27Cederholm T. Barrazoni R. Austin P. Ballmer P. Biolo G. Bischoff S.C. et al.ESPEN guidelines on definitions and terminology of clinical nutrition.Clin Nutr. 2017; 36: 49-64Abstract Full Text Full Text PDF PubMed Google Scholar, 28Cederholm T. Bosaeus I. Barazzoni R. Bauer J. Van Gossum A. Klek S. et al.Diagnostic criteria for malnutrition - an ESPEN consensus statement.Clin Nutr. 2015; 34: 335-340Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar]: Nutrition therapy is the provision of nutrition or nutrients either orally (regular diet, therapeutic diet, e.g. fortified food, oral nutritional supplements) or via enteral nutrition (EN) or parenteral nutrition (PN) to prevent or treat malnutrition. “Medical nutrition therapy is a term that encompasses oral nutritional supplements, enteral tube feeding (enteral nutrition) and parenteral nutrition” [[27]Cederholm T. Barrazoni R. Austin P. Ballmer P. Biolo G. Bischoff S.C. et al.ESPEN guidelines on definitions and terminology of clinical nutrition.Clin Nutr. 2017; 36: 49-64Abstract Full Text Full Text PDF PubMed Google Scholar]. Enteral and parenteral nutrition have traditionally been called artificial nutritional support. Nutrition therapies are individualized and targeted nutrition care measures using diet or medical nutrition therapy. Dietary advice or nutritional counselling can be part of a nutrition therapy. In the surgical patient, the indications for nutritional therapy are prevention and treatment of catabolism and malnutrition. This affects mainly the perioperative maintenance of nutritional state in order to prevent postoperative complications [[29]Chambrier C. Sztark F. Societé francophone de nutrition clinique et métabolisme (SFNEP), Societé francaise de l'anésthesie et réanimation (SFAR) French clinical guidelines on perioperative nutrition - update of the 1994 consensus conference on perioperative artificial nutrition for elective surgery in adults.J Visc Surg. 2012; 49: e325-336Crossref Google Scholar]. Therapy should start as a nutritional risk becomes apparent. Criteria for the success of the “therapeutic” indication are the so-called “outcome” parameters of mortality, morbidity, and length of hospital stay, while taking into consideration economic implications. The improvement of nutritional status and functional recovery including quality of life are most important nutritional goals in the late postoperative period. Nutrition therapy may be indicated even in patients without obvious disease-related malnutrition, if it is anticipated that the patient will be unable to eat or cannot maintain appropriate oral intake for a longer period perioperatively. In these situations, nutrition therapy may be initiated without delay. Altogether, it is strongly recommended not to wait until severe disease-related malnutrition has developed, but to start nutrition therapy early, as soon as a nutritional risk becomes apparent. Nutritional care protocols for the surgical patient must include•a detailed nutritional and medical history that includes body composition assessment•a nutrition intervention plan•an amendment of the intervention plan, where appropriate•clear and accurate documentation assessment of nutritional and clinical outcome•resistance exercise whenever possible Therefore, as a basic requirement a systematic nutritional risk screening (NRS) has to be considered in all patients on hospital admission [[30]Kondrup J. Allison S.P. Elia M. Vellas B. Plauth M. Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN) ESPEN guidelines for nutrition screening 2002.Clin Nutr. 2003; 22: 415-421Abstract Full Text Full Text PDF PubMed Scopus (1121) Google Scholar]. The items of the NRS comprise BMI <20.5 kg/m2, weight loss >5% within 3 months, diminished food intake, and severity of the disease. In older adults comprehensive geriatric assessment is necessary and should definitely include NRS [[31]Cheema F.N. Abraham N.S. Berger D.H. Albo D. Taffet G.E. Naik A.D. Novel approaches to perioperative assessment and intervention may improve long-term outcomes after colorectal cancer resection in older adults.Ann Surg. 2011; 253: 867-874Crossref PubMed Scopus (0) Google Scholar]. In order to improve oral intake documentation of food intake is necessary and nutritional counselling should be provided as needed. Oral nutritional supplements (ONS) and EN (tube feeding) as well as PN offer the possibility to increase or to ensure nutrient intake in case of insufficient oral food intake. Assessment before surgery means risk assessment according to pathophysiology [[32]Soeters P.B. Reijven P.L. van Bokhorst-de van der Schueren M.A. Schols J.M. Halfens R.J. Meijers J.M. et al.A rational approach to nutritional assessment.Clin Nutr. 2008; 27: 706-716Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar]. Severe undernutrition has long been known to be detrimental to outcome [33Studley H.M. Percentage of weight loss – a basic indicator for surgical risk in patients with chronic peptic ulcer.JAMA. 1936; 106: 458-460Crossref Google Scholar, 34van Bokhorst-de van der Schueren M.A. van Leeuwen P.A. Sauerwein H.P. Kuik D.J. Snow G.B. Quak J.J. Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications.Head Neck. 1997; 19: 419-425Crossref PubMed Google Scholar, 35Durkin M.T. Mercer K.G. McNulty M.F. Phipps L. Upperton J. Giles M. et al.Vascular surgical society of great britain and Ireland: contribution of malnutrition to postoperative morbidity in vascular surgical patients.Br J Surg. 1999; 86: 702Crossref PubMed Google Scholar, 36Pikul J. Sharpe M.D. Lowndes R. Ghent C.N. Degree of preoperative malnutrition is predictive of postoperative morbidity and mortality in liver transplant recipients.Transplantation. 1994; 57: 469-472Crossref PubMed Google Scholar]. Malnutrition is generally considered to be associated with starving and lack of food. Its presence in the Western world with an increasing percentage of obese people is frequently neither realized nor well understood. Disease Related Malnutrition (DRM) is more subtle than suggested by the World Health Organization (WHO) definition of undernutrition with a body mass index (BMI) < 18.5 kg/m2 (WHO) [28Cederholm T. Bosaeus I. Barazzoni R. Bauer J. Van Gossum A. Klek S. et al.Diagnostic criteria for malnutrition - an ESPEN consensus statement.Clin Nutr. 2015; 34: 335-340Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 37Valentini L. Volkert D. Schütz T. Ockenga J. Pirlich M. Druml W. et al.Suggestions for terminology in clinical nutrition.Clin Nutr ESPEN. 2014; 9: e97-e108Google Scholar]. Disease related weight loss in patients who are overweight is not necessarily associated with a low BMI. However, this weight loss results in changes in body composition with a loss of fat free mass inducing a “metabolic risk” which has to be kept in mind for patients undergoing major surgery with special regard to cancer. Additionally, chronic low-grade inflammation may be a component of malnutrition [[9]Soeters P.B. Schols A.M. Advances in understanding and assessing malnutrition.Curr Opin Clin Nutr Metab Care. 2009; 12: 487-494Crossref PubMed Scopus (0) Google Scholar]. ESPEN has recently defined diagnostic criteria for malnutrition according to two options [[28]Cederholm T. Bosaeus I. Barazzoni R. Bauer J. Van Gossum A. Klek S. et al.Diagnostic criteria for malnutrition - an ESPEN consensus statement.Clin Nutr. 2015; 34: 335-340Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar]•option 1: BMI <18.5 kg/m2•option 2: combined: weight loss >10% or >5% over 3 months and reduced BMI or a low fat free mass index (FFMI). Reduced BMI is <20 or <22 kg/m2 in patients younger and older than 70 years, respectively. Low FFMI is <15 and <17 kg/m2 in females and males, respectively. Because DRM is frequently not recognized and therefore untreated, metabolic factors will usually not be considered for the critical analysis of surgical morbidity and outcome. In traditional surgical care many retrospective and prospective studies (References in ESPEN guidelines 2006, [[38]Weimann A. Braga M. Harsanyi L. Laviano A. Ljungqvist O. Soeters P. et al.ESPEN guidelines on enteral nutrition: surgery including organ transplantation.Clin Nutr. 2006; 25: 224-244Abstract Full Text Full Text PDF PubMed Scopus (545) Google Scholar]) have shown clearly the prognostic influence of nutritional status on complications and mortality. A systematic review of ten studies revealed a validated nutritional tool a predictor for length of hospital stay in gastrointestinal cancer patients requiring surgery [[39]Gupta D. Vashi P.G. Lammersfeld C.A. Braun D.P. Role of nutritional status in predicting the length of stay in cancer: a systematic review of the epidemiological literature.Ann Nutr Metab. 2011; 59: 96-106Crossref PubMed Scopus (35) Google Scholar]. DRM is also relevant for outcome after organ transplantation (see references [[38]Weimann A. Braga M. Harsanyi L. Laviano A. Ljungqvist O. Soeters P. et al.ESPEN guidelines on enteral nutrition: surgery including organ transplantation.Clin Nutr. 2006; 25: 224-244Abstract Full Text Full Text PDF PubMed Scopus (545) Google Scholar]). Data from the European “NutritionDay” in about 15,000 patients clearly showed that “metabolic risk” is a factor for hospital mortality, with special focus on the elderly [[40]Hiesmayr M. Schindler K. Pernicka E. Schuh C. Schoeniger-Hekele A. Bauer P. et al.Decreased food intake is a risk factor for mortality in hospitalised patients: the NutritionDay survey 2006.Clin Nutr. 2009; 28: 484-491Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar]. According to the prospective data from a multicentre trial, most patients at risk will be found in hospital in the departments of surgery, oncology, geriatrics, and intensive care medicine. The univariate analysis revealed significant impact for the hospital complication rate: severity of the disease, age >70 years, surgery and cancer [[41]Sorensen J. Kondrup J. Prokopowicz J. Schiesser M. Krahenbuhl L. Meier R. et al.EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome.Clin Nutr. 2008; 27: 340-349Abstract Full Text Full Text PDF PubMed Scopus (248) Google Scholar]. Bearing in mind the demographic development in the Western world, surgeons will have to deal with an increased risk of developing complications in the elderly undergoing major surgery for cancer. The metabolic risk associated with DRM can be detected easily by the “Nutritional Risk Score” [[30]Kondrup J. Allison S.P. Elia M. Vellas B. Plauth M. Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN) ESPEN guidelines for nutrition screening 2002.Clin Nutr. 2003; 22: 415-421Abstract Full Text Full Text PDF PubMed Scopus (1121) Google Scholar]. This tool has been validated prospectively in recent studies for surgical patients as well [41Sorensen J. Kondrup J. Prokopowicz J. Schiesser M. Krahenbuhl L. Meier R. et al.EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome.Clin Nutr. 2008; 27: