Annals of Clinical Nutrition and Metabolism

A practical guide for enteral nutrition from the Korean Society for Parenteral and Enteral Nutrition: Part III. preparation of enteral nutrition formulas: In Seok Lee, Ye Rim Chang, Bo-Eun Kim, 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 the KSPEN Enteral Nutrition Committee; Ann Clin Nutr Metab 2026;18(1):3-9. Published online March 30, 2026; DOI: https://doi.org/10.15747/ACNM.26.0046

Abstract PDF: Purpose
This guideline was developed to provide evidence-based recommendations for the safe preparation and handling of enteral nutrition (EN) formulas in order to improve patient safety and promote standardized clinical practice in Korea.
Methods
The key questions addressed the selection of open versus closed feeding systems, the safe preparation and handling of EN formulas, precautions related to blenderized tube feeding (BTF), and essential labeling requirements. Recommendations were drafted and refined through multidisciplinary expert consensus under the auspices of the Korean Society for Parenteral and Enteral Nutrition (KSPEN).
Results
The choice of feeding system should be determined according to the patient’s condition, risk of infection, and anticipated duration of feeding. Closed feeding systems are recommended because they reduce contamination risk and nursing workload, whereas open feeding systems require strict adherence to aseptic technique. For open or reconstituted EN formulas, hang time at room temperature should not exceed 4 hours, whereas closed feeding systems should follow the manufacturer’s recommended hang time. For BTF, administration time should be limited to 2 hours to minimize bacterial growth, and their use is contraindicated in medically unstable or immunocompromised patients. Accurate labeling, including patient identifiers, formula information, administration route, and hang time, is essential to prevent administration errors.
Conclusion
These guidelines provide a practical framework for the safe preparation and management of EN formulas. Adherence to standardized preparation protocols, including appropriate feeding system selection and strict hygiene practices, is essential for reducing complications and improving the safety of EN therapy.

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Association between the calcium-to-phosphorus ratio and early hypophosphatemia in preterm infants receiving parenteral nutrition in Korea: a retrospective cohort study: Miseon Han, Jin Ok Kyun, Yoong-A Suh, Jang Hoon Lee; Ann Clin Nutr Metab 2026;18(1):44-53. Published online March 30, 2026; DOI: https://doi.org/10.15747/ACNM.25.0039

Graphical Abstract Abstract PDF Supplementary Material: Purpose
This study aimed to evaluate the association between the calcium-to-phosphorus (Ca/P) ratio and serum phosphate levels in preterm infants receiving total parenteral nutrition (TPN) and to explore Ca/P ratio ranges associated with hypophosphatemia.
Methods
We retrospectively reviewed the medical records of preterm infants admitted to the neonatal intensive care unit at Ajou University Hospital between January 2022 and June 2024. The review focused on TPN composition and serum electrolyte changes during the first week of life. Based on the cumulative Ca/P ratio during this period, infants were categorized into two groups: Ca/P-Low (mass ratio ≤1.3) and Ca/P-High (mass ratio >1.3).
Results
A total of 117 preterm infants were included in the analysis (Ca/P-Low group, n=46; Ca/P-High group, n=71). During the first week of life, the cumulative phosphorus deficit was significantly greater in the Ca/P-High group (61.4 mg/kg vs. 8.5 mg/kg; P<0.001). By day of life (DOL) 7, both hypophosphatemia and severe hypophosphatemia had increased markedly in the Ca/P-High group compared with DOL 3. In the Ca/P-High group, the incidence of hypophosphatemia increased from 44.4% on DOL 3 to 75.0% on DOL 7, while the incidence of severe hypophosphatemia increased from 4.8% to 23.1%.
Conclusion
These findings suggest that parenteral nutrition strategies may benefit from phase-adapted Ca/P ratios rather than a fixed ratio during the first week of life. A higher ratio may be considered during DOL 0–2, whereas a lower ratio may be considered during DOL 3–6, particularly when overall calcium and phosphorus supply is suboptimal.

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Association of soy oil-based lipid injectable emulsion with early body weight loss after minimally invasive esophagectomy in Japan: a retrospective cohort study: Tomonori Narita, Kazuhiko Fukatsu, Kenichi Kono, Satoshi Murakoshi, Reo Inoue, Midori Noguchi, Nana Matsumoto, Shoh Yajima, Koichi Yagi, Yoshifumi Baba; Ann Clin Nutr Metab 2026;18(1):34-43. Published online March 30, 2026; DOI: https://doi.org/10.15747/ACNM.25.0030

Graphical Abstract Abstract PDF Supplementary Material: Purpose
Postoperative body weight loss (PBWL) is associated with poor long-term outcomes following esophagectomy for esophageal cancer, underscoring the critical importance of perioperative nutritional management. Although minimally invasive procedures, such as robot-assisted radical transmediastinal esophagectomy (RA-TME), have become increasingly prevalent, perioperative nutritional strategies have received comparatively limited attention. This study evaluated the impact of soy oil-based injectable lipid emulsion (SO-ILE) on PBWL in patients undergoing RA-TME.
Methods
We retrospectively analyzed 155 patients who underwent RA-TME for esophageal or esophagogastric junction cancer at our hospital between 2011 and 2022. Patients were divided into two groups: the lipid (+) group (n=33), which received SO-ILE between postoperative days 1 and 6, and the lipid (–) group (n=122), which did not receive SO-ILE. Oral or enteral nutrition was withheld until postoperative day 6. Nutrient intake, postoperative outcomes, and nutritional status were compared between the two groups.
Results
Patient backgrounds, surgical outcomes, and postoperative complication rates were similar between the two groups. However, patients in the lipid (+) group received significantly greater total energy and nutrient intake. PBWL at 2 weeks after surgery was significantly lower in the lipid (+) group than in the lipid (–) group (5.8% vs. 7.4%; P=0.027). Univariate analysis showed that absence of SO-ILE administration was the only significant risk factor for PBWL greater than 5% at 2 weeks after RA-TME (P=0.038).
Conclusion
SO-ILE may have the potential to mitigate early PBWL after RA-TME.

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Effectiveness of perioperative rehabilitation and nutrition in esophageal cancer: a narrative review: Ryoma Haneda, Yuki Sakai, Kenichi Sekimori, Tomohiro Murakami, Eisuke Booka, Tomohiro Matsumoto, Hirotoshi Kikuchi, Yoshihiro Hiramatsu, Hiroya Takeuchi; Ann Clin Nutr Metab 2026;18(1):18-26. Published online March 30, 2026; DOI: https://doi.org/10.15747/ACNM.25.0021

Abstract PDF: Purpose
Esophageal cancer surgery requires robust perioperative management to reduce its high rate of complications. This review evaluates the clinical utility of comprehensive exercise and nutritional therapy, with a specific focus on initiatives led by the multidisciplinary Hamamatsu Perioperative Care Team (HOPE), established at Hamamatsu University Hospital to optimize patient safety and postoperative recovery outcomes.
Current concept
The HOPE protocol involves a diverse team, including surgeons, nurses, pharmacists, and dietitians, who collaboratively implement a multifaceted perioperative care bundle. These interventions include strict smoking cessation, intensive oral care, and immunonutrition incorporating n-3 fatty acids. A distinctive feature of this program is the integration of patient-reported treatment diaries and wearable fitness tracking devices (WFTs) to visualize daily activity, thereby helping to sustain patient motivation. Preoperative rehabilitation focuses on preventing sarcopenia through combined aerobic and resistance training, while postoperative care emphasizes immediate enteral nutrition and early mobilization. Retrospective analyses demonstrated that HOPE implementation reduced Clavien-Dindo grade III or higher infectious complications, pneumonia and surgical site infections, compared with historical controls. In addition, a propensity score–matched analysis showed that WFT users experienced lower pneumonia rates, shorter hospital stays, and better preservation of nutritional markers, including albumin and transthyretin, during the recovery phase compared with non-users.
Conclusion
The HOPE strategy illustrates that combining standard nutritional support and exercise therapy with digital tools enables individualized rehabilitation. This integrated approach reduces morbidity and preserves function, strongly suggesting that incorporation of wearable technology into established surgical care protocols represents a strategy for improving long-term outcomes in high-risk cancer patients.

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Bedside support for neurologically impaired patients via nutritional evaluations, swallowing function assessments, and gastrointestinal function tests: a narrative review: Daisuke Masui, Naoki Hashizume, Yoshinori Koga, Hiroto Eto, Hiroki Yoshida, Shotaro Taki, Takato Aikoh, Shiori Tsuruhisa, Tomohiro Kurahachi, Naruki Higashidate, Tatsuru Kaji; Ann Clin Nutr Metab 2026;18(1):10-17. Published online March 30, 2026; DOI: https://doi.org/10.15747/ACNM.25.0018

Abstract PDF: Purpose
Neurologically impaired patients often experience complex challenges in respiratory and nutritional management that may necessitate surgical intervention. Furthermore, some patients admitted to specialized facilities for neurologically impaired individuals do not receive adequate postoperative follow-up after being transferred. Kurume University Hospital has established a system of continuous routine rounds at such facilities. This review aims to describe the rationale, methods, and outcomes of multidisciplinary bedside support, with particular emphasis on nutritional evaluation, swallowing function assessment, and gastrointestinal function testing.
Current concept
Routine collaboration between pediatric surgeons and facility-based pediatricians enables continuous perioperative management. Preoperatively, patient background, nutritional status, and family preferences are recorded through structured communication and shared decision-making tools, such as the Ottawa Personal Decision Guide. During hospitalization, multidisciplinary evaluations include bioelectrical impedance analysis for nutritional assessment, endoscopic and pH impedance testing for swallowing function, and multichannel intraluminal impedance monitoring for gastroesophageal reflux. Postoperatively, periodic facility rounds ensure ongoing evaluation, with repeated assessments guiding nutritional optimization, early complication detection, and timely surgical consultation. This approach provides families and healthcare teams with detailed information on functional outcomes, strengthens trust, and enhances continuity of care. Sustained bedside engagement at facilities for neurologically impaired patients improves pre- and postoperative monitoring, promotes seamless collaboration between institutions, and ensures individualized evaluation of nutrition, swallowing, and gastrointestinal function.
Conclusion
By providing actionable data to families and multidisciplinary teams, this model strengthens shared decision-making and supports long-term outcomes. The system may serve as a framework for integrated perioperative care in similar high-risk patient populations.

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Current status and short-term results regarding frailty in patients undergoing gastrointestinal cancer resection in Japan: a retrospective cohort study: Asuka Yasueda, Junichi Nishimura, Seiji Ikeda, Naotsugu Haraguchi, Hirofumi Akita, Hiroshi Wada, Chu Matsuda, Takeshi Omori, Masayoshi Yasui, Hironari Tamiya, Hideaki Tahara, Hiroshi Miyata; Ann Clin Nutr Metab 2026;18(1):54-62. Published online March 30, 2026; DOI: https://doi.org/10.15747/ACNM.25.0013

Graphical Abstract Abstract PDF: Purpose
Frailty is a state of physical and cognitive decline that exists between robust health and the need for nursing care. Frailty is reported to occur at a high rate among patients with cancer and is associated with postoperative complications, such as delirium, infection, reduced survival, and rehospitalization. In this study, we investigated the incidence of frailty and surgical outcomes in patients who underwent surgery for gastrointestinal cancer.
Methods
A total of 201 patients who underwent preoperative physical assessment at Osaka International Cancer Institute between July and September 2021 were included. The Japanese version of the Cardiovascular Health Study (J-CHS) index was used to assess the frequency of frailty and related postoperative outcomes.
Results
Among the 201 patients, 27 (13%) were classified as frail and 126 (63%) as pre-frail. Of the 27 frail patients, 22 (81%) were older adults—a significantly higher proportion compared to the pre-frail/robust group (P=0.004). The median hospital stay for frail patients was 17 days (range, 5–98 days), which was significantly longer than that for robust patients (P<0.001). Postoperative complications occurred in 13 frail patients (48%), which was higher than in pre-frail (n=36, 29%) and robust (n=6, 13%) patients. Furthermore, multivariate analysis showed that frailty was an independent risk factor for postoperative complications.
Conclusion
These findings indicate that frailty is common among older adults with gastrointestinal cancer and has a significant impact on both the length of hospital stay and the risk of postoperative complications.

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A practical guide for enteral nutrition from the Korean Society for Parenteral and Enteral Nutrition: Part II. selection and initiation of enteral feeding routes: Ja Kyung Min, Ye Rim Chang, Bo-Eun Kim, In Seok Lee, Jung Mi Song, Hyunjung Kim, Jae Hak Kim, Kyung Won Seo, Sung Shin Kim, Chi-Min Park, Jeongyun Park, Eunjung Kim, Eunmi Sul, Sung-Sik Han, Jeong Wook Kim, Seungwan Ryu, Minji Seok, Jinhee Yoon, Eunhee Kong, Youn Soo Cho, Jeong Meen Seo, for KSPEN Enteral Nutrition Committee; Ann Clin Nutr Metab 2025;17(3):165-171. Published online December 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0037

Abstract PDF: Purpose
We developed evidence-based recommendations for selecting and initiating the enteral nutrition (EN) delivery route in adult and pediatric patients to improve safety and standardize practice in Korea.
Methods
Key questions covered feeding tube selection, methods to verify tube placement, confirmation in pediatric patients, and timing of EN following percutaneous endoscopic gastrostomy (PEG). Recommendations were drafted and refined through multidisciplinary expert consensus under the Korean Society for Parenteral and Enteral Nutrition (KSPEN).
Results
Feeding tube selection should be based on gastrointestinal anatomy, function, and expected EN duration. Short-term feeding is recommended with nasogastric or orogastric tubes, whereas long-term feeding should use percutaneous or surgical routes such as PEG. Tube position must always be verified before use, preferably with radiography or pH testing; auscultation alone is unreliable and should not be used. In pediatric patients, radiographic confirmation remains the gold standard, although pH testing and insertion-length assessment may be considered when imaging is not feasible. After PEG, EN can be initiated safely within 4 hours in both adults and children without increasing complications if trained staff monitor for leakage or infection.
Conclusion
This guideline offers a structured framework for safe and timely EN tailored to patient characteristics. Early verification and multidisciplinary collaboration help reduce complication, improving outcomes of EN therapy.

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Preprocedural prognostic nutritional index predicts early gastrointestinal symptoms after percutaneous endoscopic gastrostomy or percutaneous radiologic gastrostomy in Korea: a retrospective cohort study: Yoonhong Kim, Jee Young Lee, Yeajin Moon, Seung Hun Lee, Kyung Won Seo, Ki Hyun Kim; Ann Clin Nutr Metab 2025;17(3):196-202. Published online December 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0032

Graphical Abstract Abstract PDF: Purpose
The prognostic nutritional index (PNI) reflects immunonutritional status and is a well-established predictor of surgical outcomes. Although its association with post-gastrostomy mortality has been documented, its relationship with early gastrointestinal (GI) symptoms remains unclear. This study aimed to evaluate whether the preprocedural PNI predicts early GI symptoms following percutaneous gastrostomy, including percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG).
Methods
This retrospective study included 71 adults who underwent PEG or PRG. Early GI symptoms, such as nausea, vomiting, and diarrhea, occurring within 7 days were recorded. The preprocedural PNI, neutrophil-to-lymphocyte ratio (NLR), and the C-reactive protein (CRP)-to-albumin ratio were analyzed using logistic regression to identify predictors. Receiver operating characteristic (ROC) analysis was performed to assess the PNI’s discriminative performance.
Results
Early GI symptoms occurred in 21 of 71 patients (29.6%). In univariate analysis, the PNI (P=0.009) and CRP-to-albumin ratio (P=0.018) were significant predictors, whereas NLR was not (P=0.125). After adjustment for potential confounders, including age, sex, body mass index, and NLR, the PNI remained an independent predictor of early GI symptoms (adjusted odds ratio, 0.90; 95% confidence interval, 0.83–0.98; P=0.021). ROC analysis for the PNI produced an area under the curve of 0.696, with an optimal cutoff value of 41.3 (sensitivity 70.6%, specificity 66.7%).
Conclusion
A lower preprocedural PNI is independently associated with the development of early GI symptoms after gastrostomy. The PNI may serve as a practical screening tool to identify high-risk patients who could benefit from preemptive nutritional optimization.

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Penetration of a nasogastric tube by a stylet during insertion: Akihide Takami, Haruka Tsuji, Kazuya Omura; Ann Clin Nutr Metab 2025;17(3):210-211. Published online December 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0029

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Perioperative nutritional practices and pediatric nutrition support team implementation in Korea: a cross-sectional study: Dayoung Ko, Honam Hwang, Hee-Beom Yang, Joong Kee Youn, Hyun-Young Kim; Ann Clin Nutr Metab 2025;17(3):181-187. Published online December 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0027

Graphical Abstract Abstract PDF Supplementary Material: Purpose
Pediatric surgical patients are vulnerable to perioperative malnutrition, yet standardized nutritional care and structured nutrition support team (NST) involvement remain inconsistent across institutions. Although multidisciplinary nutritional support has gained increasing attention, data on pediatric NST practices within surgical settings in Korea are limited. This study examined the availability and composition of pediatric NSTs, perioperative nutritional practices, and barriers in hospitals performing pediatric surgery.
Methods
A nationwide cross-sectional survey was conducted among tertiary and secondary hospitals that perform pediatric surgery in Korea. The questionnaire assessed hospital characteristics, the presence and composition of pediatric NSTs, perioperative nutritional screening and support practices, monitoring protocols.
Results
A total of 12 hospitals participated. Although all were high-capacity institutions, only half reported having a pediatric NST. Routine preoperative nutritional screening was performed in 50% of hospitals, and validated tools such as Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) and Pediatric Yorkhill Malnutrition Score (PYMS) were used in 41.7%. Hospitals with a pediatric NST more frequently had institutional protocols for nutritional evaluation (66.7% vs. 16.7%) and were more likely to administer central venous parenteral nutrition postoperatively (83.3% vs. 0%, P=0.015). Enhanced Recovery After Surgery protocols were implemented in only two hospitals (16.7%). Major barriers to pediatric NST operation included insufficient staffing and time constraints.
Conclusion
Pediatric NSTs and standardized perioperative nutrition protocols remain underutilized in Korean surgical centers. Institutions with a pediatric NST demonstrated more structured nutritional practices. Expanding NST infrastructure and establishing standardized perioperative protocols for pediatric surgical patients may enhance the quality and consistency of nutritional care.

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Impact of tube feeding after pancreaticoduodenectomy on nutritional intake and status: a retrospective cohort study in Japan: Masaharu Ishida, Masahiro Iseki, Shuichiro Hayashi, Aya Noguchi, Hideaki Sato, Shingo Yoshimachi, Akiko Kusaka, Mitsuhiro Shimura, Shuichi Aoki, Daisuke Douchi, Takayuki Miura, Shimpei Maeda, Masamichi Mizuma, Kei Nakagawa, Takashi Kamei, Michiaki Unno; Ann Clin Nutr Metab 2025;17(3):203-209. Published online December 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0020

Graphical Abstract Abstract PDF: Purpose
Pancreaticoduodenectomy (PD) is one of the most invasive procedures in gastrointestinal surgery. However, the clinical significance of postoperative tube feeding remains unclear. This study investigated the impact of enteral nutrition (EN) on the postoperative nutritional status of patients undergoing PD.
Methods
We retrospectively analyzed 129 patients who underwent PD at Tohoku University Hospital. Nutritional intake and status, evaluated using the Controlling Nutritional Status score, were compared between two groups: an EN group (97 patients) and a non-EN group (32 patients).
Results
There were no significant differences between the two groups in age, sex, body mass index, underlying diseases, operative duration, blood loss, postoperative pancreatic fistula, postoperative complications, delayed gastric emptying, or length of hospital stay. Although the EN group showed improvements in nutritional status both at discharge and compared with preoperative values, none of these changes reached statistical significance. Oral caloric intake was significantly higher in the non-EN group (P=0.01). In contrast, total energy intake was higher in the EN group, but this difference did not reach statistical significance (P=0.07).
Conclusion
Tube feeding after PD did not significantly influence postoperative nutritional status or overall nutritional intake. These findings suggest that EN offers no clear advantage over other approaches; however, further research is warranted to validate these results, refine existing guidelines, and optimize postoperative patient management.

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Current practices and challenges in nutrition support team activities, 2025 in Korea: a multicenter cross-sectional descriptive study: So Hyun Nam; Ann Clin Nutr Metab 2025;17(2):97-103. Published online August 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0026

Abstract PDF Supplementary Material

Purpose
This study aimed to evaluate the current practices, activities, and challenges of nutrition support teams (NSTs) in Korea. The assessment was conducted as part of the 4th NST Leadership Program of the Korean Society of Surgical Metabolism and Nutrition held in 2025, which seeks to foster leadership and enhance team functionality.
Methods
A nationwide survey was conducted in February 2025 among 54 NST members from 44 institutions. The survey explored team composition, consultation volume, educational programs, barriers to implementation, institutional support, and reimbursement challenges.
Results
Of the 44 participating hospitals, most (86.4%) operated a single NST, with multidisciplinary physician involvement from over three specialties in 77.2% of cases. Inpatient referrals to NSTs were generally low, with less than 10% at 63% of institutions. Only 40.9% had an individual office, and formal incentive systems were reported in 18.1% of hospitals. Educational programs for in-hospital staff were limited (29.5%), and less than half conducted regular academic meetings. Rates of adoption of NST recommendations varied widely, with barriers including a lack of engagement from attending physicians, failure to review the recommendations, and department-specific clinical policies. Efforts to promote NST activation included computerized prescription systems, automated referral workflows, staff education, and quality improvement initiatives. Participants focused on sharing effective NST cases, building incentives, exchanging clinical insights, clarifying team roles and leadership, and developing unified practice guidelines.
Conclusion
NSTs in Korea are well established but face ongoing challenges in collaboration and sustainability. Continued leadership and policy support are crucial for enhancing team performance and improving patient outcomes.

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Perioperative nutritional practices and pediatric nutrition support team implementation in Korea: a cross-sectional study
Dayoung Ko, Honam Hwang, Hee-Beom Yang, Joong Kee Youn, Hyun-Young Kim
Ann Clin Nutr Metab.2025; 17(3): 181. CrossRef

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Improving the usability of lipid emulsions and optimizing their user-friendliness: a narrative review: Keisuke Kubota, Natsuko Ichikawa, Kazuhiro Isoda, Misato Enomoto, Miyoko Kosugi, Mari Tanabe, Naoya Sakuraba, Sayuri Endo, Atsushi Suzuki, Masanori Hashimoto; Ann Clin Nutr Metab 2025;17(2):104-113. Published online August 1, 2025; DOI: https://doi.org/10.15747/ACNM.25.0015

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