Annals of Clinical Nutrition and Metabolism

Bridging evidence and clinical practice: a practical guide for enteral nutrition from the Korean Society for Parenteral and Enteral Nutrition: Suk-Kyung Hong; Ann Clin Nutr Metab 2025;17(1):1-2. Published online April 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0008

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A practical guide for enteral nutrition from the Korean Society for Parenteral and Enteral Nutrition: Part I. prescribing enteral nutrition orders: Ye Rim Chang, Bo-Eun Kim, In Seok Lee, Youn Soo Cho, Sung-Sik Han, Eunjung Kim, Hyunjung Kim, Jae Hak Kim, Jeong Wook Kim, Sung Shin Kim, Eunhee Kong, Ja Kyung Min, Chi-Min Park, Jeongyun Park, Seungwan Ryu, Kyung Won Seo, Jung Mi Song, Minji Seok, Eun-Mi Seol, Jinhee Yoon, Jeong Meen Seo, for KSPEN Enteral Nutrition Committee; Ann Clin Nutr Metab 2025;17(1):3-8. Published online April 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0002

Purpose
This study aimed to develop a comprehensive practical guide for enteral nutrition (EN) designed to enhance patient safety and reduce complications in Korea. Under the leadership of the Korean Society for Parenteral and Enteral Nutrition (KSPEN), the initiative sought to standardize EN procedures, improve decision-making, and promote effective multidisciplinary communication.
Methods
The KSPEN EN committee identified key questions related to EN practices and organized them into seven sections such as prescribing, delivery route selection, formula preparation, administration, and quality management. Twenty-one experts, selected based on their expertise, conducted a thorough literature review to formulate evidence-based recommendations. Drafts underwent peer review both within and across disciplines, with final revisions completed by the KSPEN Guideline Committee. The guide, which will be published in three installments, addresses critical elements of EN therapy and safety protocols.
Results
The practical guide recommends that EN orders include detailed elements and advocates the use of electronic medical records for communication. Standardized prescription forms and supplementary safety measures are outlined. Review frequency is adjusted according to patient condition—daily for critically ill or unstable patients and as dictated by institutional protocols for stable patients. Evidence indicates that adherence to these protocols reduces mortality, complications, and prescription errors.
Conclusion
The KSPEN practical guide offers a robust framework for the safe delivery of EN tailored to Korea’s healthcare context. It emphasizes standardized protocols and interdisciplinary collaboration to improve nutritional outcomes, patient safety, and operational efficiency. Rigorous implementation and monitoring of adherence are critical for its success.

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Bridging evidence and clinical practice: a practical guide for enteral nutrition from the Korean Society for Parenteral and Enteral Nutrition
Suk-Kyung Hong
Ann Clin Nutr Metab.2025; 17(1): 1. CrossRef

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Pathogenesis, risk factors, and management of postoperative delayed gastric emptying after distal gastrectomy: a narrative review: Cheong Ah Oh; Ann Clin Nutr Metab 2025;17(1):9-17. Published online April 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0007

Abstract PDF ePub: Purpose
This narrative review elucidates the complex pathogenesis, key risk factors, and effective management strategies for postoperative delayed gastric emptying (DGE) following distal gastrectomy with D2 lymphadenectomy, a definitive procedure for middle and lower gastric cancer. It also explores opportunities for improved prevention and innovative treatment options. Current concept: DGE significantly disrupts gastric motility and presents with symptoms such as early satiety, postprandial fullness, nausea, vomiting, and gastric atony. Although rarely fatal, DGE hampers oral intake, prolongs hospital stays, and diminishes quality of life. Current evidence indicates that DGE is a multifactorial disorder resulting from an interplay of vagal nerve disruption, damage to smooth muscle and interstitial cells of Cajal, imbalances in gastrointestinal hormones, and postoperative gut microbiome dysbiosis. Patient-specific factors, including advanced age, poor nutritional status, diabetes, and preoperative pyloric obstruction, along with surgical factors (most notably Billroth II reconstruction), further increase the risk of DGE. Management involves dietary modifications, prokinetic agents (such as metoclopramide and selective 5-HT4 agonists like prucalopride), and gastric decompression.
Conclusion
DGE is a challenging complication following gastrectomy that demands a deeper understanding of its underlying mechanisms to improve patient outcomes. Emerging therapies, including microbiota modulation and advanced pharmacological agents, offer promising new treatment avenues.

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Perioperative nutritional management to improve long-term outcomes in critically ill perioperative organ transplant patients: a narrative review: Toshimi Kaido; Ann Clin Nutr Metab 2025;17(1):18-24. Published online April 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0005

Abstract PDF ePub: Purpose
This review examines the significance of perioperative nutritional management in organ transplantation, with a particular focus on liver transplantation. Organ transplant recipients often experience malnutrition and sarcopenia due to nutritional and metabolic abnormalities associated with organ dysfunction. Because transplantation is a highly invasive procedure, optimizing perioperative nutritional care is critical for improving short-term outcomes and reducing postoperative infection-related mortality. Current concept: Recent clinical investigations have shown that liver transplant recipients, who are frequently afflicted with end-stage liver disease and uncompensated cirrhosis, are particularly vulnerable to protein-energy malnutrition and secondary sarcopenia. Our analysis identified low pre-transplant nutritional status and the absence of preoperative branched-chain amino acid supplementation as independent risk factors for post-transplant sepsis. In response, we developed a customized nutritional therapy protocol that incorporates precise body composition analysis, serial measurements of biochemical markers (including prealbumin, zinc, and the branched-chain amino acid/tyrosine ratio), and targeted supplementation with branched-chain amino acids, zinc acetate, and synbiotics. Early initiation of enteral nutrition coupled with postoperative rehabilitative interventions resulted in improved outcomes. In addition, stratified body composition parameters correlated with survival differences and informed revised transplantation criteria.
Conclusion
Tailored perioperative nutritional management and rehabilitative strategies are essential for improving early postoperative outcomes in liver transplantation. These findings underscore the need for proactive nutritional assessment and intervention, which may represent a breakthrough in transplant prognosis. Future research should refine nutritional protocols and integrate novel biomarkers, while education and interdisciplinary collaboration remain crucial for enhancing transplant outcomes and reducing complications.

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Development of a pre- and re-habilitation protocol for gastrointestinal cancer surgery: Eun Young Kim, Jung Hoon Bae, Jiseon Kim, Eun Joo Yang, Sang-Jae Park, In Kyu Lee, on behalf of the Task Force Team for Development and Trial Application of Pre/Rehabilitation Protocol in GI Cancer Surgery; Ann Clin Nutr Metab 2025;17(1):25-40. Published online April 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0001

Abstract PDF Supplementary Material ePub: Purpose
Surgical resection is the primary curative treatment for gastrointestinal (GI) cancer; however, it is associated with high postoperative complication rates and impaired recovery. Frailty, malnutrition, and sarcopenia increase morbidity and mortality, underscoring the need for perioperative rehabilitation programs. Standardized rehabilitation protocols during the perioperative period are currently lacking in Korea. We aimed to develop an evidence-based rehabilitation protocol for GI cancer patients to enhance postoperative outcomes and facilitate clinical implementation.
Methods
A multidisciplinary task force team comprising experts in surgery, clinical nutrition, and rehabilitation medicine conducted a systematic literature search and comprehensive review from 2012 to 2022 to develop a standardized pre- and re-habilitation protocol for GI cancer surgery. The protocol underwent external validation and subsequent refinements before being finalized through expert consensus.
Results
The protocol development process was organized into four consecutive phases: keyword selection, literature review and case report form development, initial protocol drafting, and external validation leading to the final version of the protocol. The final version of the rehabilitation protocol is presented in the main text and included as Supplements.
Conclusion
This protocol provides a standardized clinical guideline based on the latest evidence-based pre- and re-habilitation strategies and is designed for seamless integration into routine clinical practice. By facilitating proactive rehabilitation interventions, it aims to improve outcomes in GI cancer patients who are at high risk of postoperative complications, functional decline, and malnutrition.

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Comparison of efficacy of enteral versus parenteral nutrition in patients after esophagectomy in Malaysia: a prospective cohort study: Ramizah Mohd Shariff, Sze Chee Tee, Shukri Jahit Mohammad, Khei Choong Khong; Ann Clin Nutr Metab 2025;17(1):41-49. Published online April 1, 2025; DOI: https://doi.org/10.15747/ACNM.24.016

Graphical Abstract Abstract PDF: Purpose
This study aims to assess the effectiveness of enteral versus parenteral feeding in patients after esophagectomy.
Methods
This a prospective cohort study of post-esophagectomy intensive care unit (ICU) patients over 12 months in the National Cancer Institute, Malaysia. Early enteral feeding followed the Enhanced Recovery After Surgery protocol, and parenteral nutrition (PN) was considered if there was a risk for conduit ischemia. It compared the effectiveness of enteral versus PN following esophagectomy, and assessed the correlations between biochemical nutritional markers and hospital lengths of stay or ventilation days.
Results
It included two cohorts receiving PN (n=11) or enteral nutrition (EN) (n=11) following elective esophagectomy. Preoperative weight, body mass index, and Subjective Global Assessment were higher in the EN group (P=0.033, P=0.021, P=0.031, respectively). Nutritional interruption occurred more frequently in the EN group (63.7%) compared to the PN group (P=0.001). Mean levels of energy and protein received were 93.1 kcal/kg and 1.4 g/kg for PN versus 92.4 kcal/kg and 1.2 g/kg for EN (P=0.893, P=0.036). The median lengths of ICU stay (P=0.688) and postoperative stay (P=0.947) between groups showed no significant difference. In addition, 30-day mortality (P=0.214) and other postoperative complications (P>0.05) were comparable in the two groups.
Conclusion
Early initiation of supplementary PN due to significant interruption in EN led to higher protein intake compared to the EN group. However, there were no significant differences in postoperative outcomes, including 30-day mortality, ICU length of stay, and ventilation days. PN ensures adequate nutritional intake, especially in terms of protein delivery, without adversely affecting postoperative recovery and clinical outcomes.

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Impact of postoperative nutritional status on the patients’ clinical outcomes and knee biomechanics following total knee arthroplasty in Japan: a prospective cohort study: Kenichi Kono, Tetsuya Tomita, Takaharu Yamazaki, Masashi Tamaki, Shuji Taketomi, Ryota Yamagami, Reo Inoue, Yuki Taniguchi, Sakae Tanaka, Kazuhiko Fukatsu; Ann Clin Nutr Metab 2025;17(1):50-57. Published online April 1, 2025; DOI: https://doi.org/10.15747/ACNM.24.019

Graphical Abstract Abstract PDF Supplementary Material: Purpose
The impact of postoperative nutritional status on clinical outcomes and biomechanics following total knee arthroplasty remains largely unknown. This study aimed to assess this question using the prognostic nutritional index to evaluate the nutritional status of orthopedic participants.
Methods
Patients with knee osteoarthritis who underwent total knee arthroplasty (n=49) in Japan were divided into two groups based on their 1-week postoperative prognostic nutritional index. Group L patients had a prognostic nutritional index <40, whereas Group H comprised patients with a prognostic nutritional index ≥40. Postoperative improvements in Knee Injury and Osteoarthritis Outcome Score were evaluated. The patients performed squats under single-fluoroscopic surveillance in the sagittal plane for biomechanical evaluation. A two-dimensional/three-dimensional registration technique was employed to measure the tibiofemoral kinematics. The axial rotation of the femoral component relative to the tibial component and the anteroposterior translation of the medial and lateral femorotibial contact points were measured.
Results
Group H showed significantly higher pain scores than Group L at 12 and 36 months postoperatively and a significantly higher symptom score at 36 months postoperatively. The kinematic comparison revealed that the axial external rotation in Group L was larger than that in Group H from 70° to 80° with flexion. Moreover, in the medial anteroposterior translation, Group L was more anteriorly located than Group H, with flexion beyond 30°.
Conclusion
The results suggest that a high postoperative nutritional status significantly improved pain and other symptoms and was associated with better knee biomechanics following total knee arthroplasty.

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The enteral feeding tube access route in esophageal cancer surgery in Japan: a retrospective cohort study: Hiroyuki Kitagawa, Keiichiro Yokota, Tsutomu Namikawa, Kazuhiro Hanazaki; Ann Clin Nutr Metab 2025;17(1):58-65. Published online April 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0003

Graphical Abstract Abstract PDF ePub: Purpose
Feeding catheter jejunostomy is a useful access route for early enteral nutrition during esophageal cancer surgery. However, it may lead to postoperative bowel obstruction associated with feeding jejunostomy (BOFJ). To prevent BOFJ, we introduced feeding catheter duodenostomy via the round ligament in 2018. This study aimed to compare the incidence of BOFJ and postoperative body weight changes between feeding catheter jejunostomy and duodenostomy.
Methods
A total of 109 patients who underwent thoracoscopic esophagectomy and gastric tube reconstruction for esophageal cancer at Kochi Medical School Hospital between March 2013 and November 2020 were included. Preoperative patient characteristics (age, sex, preoperative weight, body mass index, cancer stage, and preoperative treatment), surgical outcomes (operative time, blood loss, and postoperative complications [wound infection, pneumonia, anastomotic leakage, BOFJ]), and body weight changes at 1, 3, 6, and 12 months post-surgery were compared between the jejunostomy (J) and duodenostomy (D) groups.
Results
The D group consisted of 35 patients. No significant differences were observed between the groups regarding age, sex, weight, body mass index, cancer stage, operative time, postoperative complications, or duration of tube placement. However, the D group had a significantly lower rate of preoperative chemotherapy (45.7% vs. 78.4%, P=0.001) and lower operative blood loss (120 mL vs. 150 mL, P=0.046) than the J group. All 12 cases of BOFJ occurred in the J group. Furthermore, the D group experienced a significantly lower weight loss ratio at 1 month postoperatively (93.9% vs. 91.8%, P=0.039).
Conclusion
In thoracoscopic esophagectomy, feeding duodenostomy may prevent bowel obstruction and reduce early postoperative weight loss without increasing operative time compared with feeding catheter jejunostomy.

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Perioperative outcomes of older adult patients with pancreatic cancer based on nutritional status: a retrospective cohorat study: Takanori Morikawa, Masaharu Ishida, Masamichi Mizuma, Kei Nakagawa, Takashi Kamei, Michiaki Unno; Ann Clin Nutr Metab 2025;17(1):66-74. Published online April 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.001

Abstract PDF: Purpose
This study investigated the effects of preoperative nutritional status on postoperative outcomes in older adult patients with pancreatic adenocarcinoma.
Methods
The background and perioperative factors of patients who underwent pancreatectomy for pancreatic adenocarcinoma between 2007 and 2020 were retrospectively analyzed.
Results
Patients aged 75 years or over (older adults) were significantly associated with hypertension, upfront surgery, and lower prognostic nutritional index. In addition, these patients had a significantly lower rate of portal vein resection, less blood loss, and shorter operation time than patients aged less than 75 years (non-older adults). During the postoperative course, older adult patients had a higher rate of pneumonia and lower overall survival than younger patients, although recurrence‐free survival was comparable. In addition, older adult patients showed preoperative malnutrition as a risk factor for postoperative in‐hospital death.
Conclusion
Surgical treatment for pancreatic cancer in older adult patients was performed safely. However, preoperative malnutrition is a risk factor for in‐hospital death and such patients require nutritional support and less‐invasive surgery.

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Association between decreased dietary intake during hospitalization and long-term weight loss in postoperative gastric cancer patients over 75 years of age: a retrospective cohort study: Daiki Tabe, Isao Miyajima, Akira Tsukada; Ann Clin Nutr Metab 2025;17(1):75-84. Published online April 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0004

Abstract PDF ePub: Purpose
Weight loss following gastrectomy is a significant concern, and maintaining adequate nutrition is necessary, especially given the growing number of older adult patients. This study examined the relationship between postoperative food intake and long-term weight loss in postgastrectomy patients aged ≥75 years.
Methods
Out of 88 patients who underwent gastrectomy for gastric cancer at our institute, 46 were aged ≥75 years. These patients were divided into two groups: one with an average energy intake exceeding 50% of the basal metabolic rate and one with an intake below 50% of the basal metabolic rate. The percentage change in body weight up to 6 months post-surgery was compared between the groups.
Results
In the group with higher dietary intake, the rate of weight change at 3 and 6 months postoperatively was lower, and fewer patients received postoperative adjuvant chemotherapy.
Conclusion
Poor postoperative food intake may serve as a predictor of weight loss up to 3 months following surgery in postgastrectomy patients aged ≥75 years.

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Effects of enteral nutrition formulas with varying carbohydrate amounts on glycemic control in diabetic mice: Yukari Miki, Kazuo Hino; Ann Clin Nutr Metab 2025;17(1):85-93. Published online April 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0006

Abstract PDF ePub: Purpose
This study evaluated the effects of an 8‑week liquid diets with different carbohydrate contents–64% energy in HINE E‑Gel (ST) and 50% energy in HINE E‑Gel LC (LC)–on glycemic control and nutritional status in a mouse model of type 2 diabetes mellitus (db/db mice). The objective was to determine whether reducing carbohydrate intake within the Dietary Reference Intakes for Japanese people improves glycemic control indices, addressing the evidence gap in regarding the long‑term safety and efficacy of low‑carbohydrate enteral nutrition in patients with diabetes.
Methods
db/db mice (n=10 per group) and non‑diabetic db/m mice (n=4) as controls were fed ST, LC, or AIN‑93G diets ad libitum for 8 weeks. The diets primarily differed in carbohydrate content (64% in ST vs. 50% in LC). Blood glucose and glycated hemoglobin (HbA1c), plasma glucose and glycoalbumin, organ weights, and renal function markers were measured weekly or at 4 and 8 weeks. Histopathological examinations of the liver and kidneys were performed at 8 weeks.
Results
At 8 weeks, the LC group showed significantly lower plasma glucose (P=0.0051) and glycoalbumin (P=0.0013) levels compared to the ST group, with a trend toward lower HbA1c (P=0.0514). Although body weight was significantly higher in the LC group (P=0.0038), there were no significant differences between the ST and LC groups in caloric intake, renal function, or histopathological findings.
Conclusion
Reducing carbohydrate intake to 50% of total energy within dietary guidelines may improve glycemic control in diabetic mice, suggesting the need for further long‑term evaluation for clinical applications.

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