The updated recommendations for medical nutrition in the perioperative period: a focus on early oral intake

PURPOSE OF REVIEW: Early oral feeding after gastrointestinal surgery is safe, promotes recovery, preserves gut integrity and aligns with enhanced recovery after surgery (ERAS) pathways. However, individualization and adaption of the pathway may be necessary postoperatively particularly after upper gastrointestinal procedures, where energy and protein requirements often remain unmet. The 2025 ESPEN guideline update advocates early oral/tube feeding while addressing supplementation strategies. The purpose of this review is to discuss the updated recommendations regarding the very recent literature. RECENT FINDINGS: Early oral intake within 24 h is safe across gastrointestinal surgeries, shortening hospital stay, bowel recovery time and infectious complications without increasing the risk for anastomotic leaks. The choice of oral diet should be individualized and adapted to the performed surgery. Yet, the energy intake remains often inadequate, in particular after upper gastrointestinal surgery, necessitating monitoring and supplementation with enteral or parenteral nutrition if needed. Enteral nutrition via intraoperatively placed feeding jejunostomy should be considered in malnourished or high-risk patients in esophagectomy, total gastrectomy and pancreatoduodenectomy, to improve nutritional status and support weight maintenance, particularly in the postdischarge phase and during adjuvant therapy. SUMMARY: Early oral feeding is feasible and preferred after gastrointestinal surgery, with enteral supplementation provided as needed in high-risk patients. Parenteral nutrition should be administered when patients cannot cover at least 50% of energy needs within 3-4 days. Guideline implementation gaps persist and standardized protocols, screening and nutrition support teams are essential for optimal postoperative nutritional support. More studies are required to evaluate the efficacy and indication of supplementing enteral and parenteral nutrition specifically in the context of ERAS protocols.