ESPEN指南外科臨床營(yíng)養(yǎng)

ESPEN指南：外科臨床營(yíng)養(yǎng)早期經(jīng)口飼養(yǎng)是手術(shù)患者營(yíng)養(yǎng)的首選方式。營(yíng)養(yǎng)療法可防備大手術(shù)后飼養(yǎng)不足的風(fēng)險(xiǎn)。考慮到營(yíng)養(yǎng)不良和飼養(yǎng)不足是術(shù)后并發(fā)癥的風(fēng)險(xiǎn)峻素，早期腸內(nèi)飼養(yǎng)對(duì)于任何有營(yíng)養(yǎng)風(fēng)險(xiǎn)的手術(shù)患者特別重要，特別是那些進(jìn)行上消化道手術(shù)的患者。該指南的要點(diǎn)是涵蓋術(shù)后加速康復(fù)外科（ERAS）看法和進(jìn)行大手術(shù)患者的特別營(yíng)養(yǎng)需求，比方癌癥，誠(chéng)然供應(yīng)最正確圍手術(shù)期醫(yī)療，但是依舊出現(xiàn)嚴(yán)重并發(fā)癥。從代謝和營(yíng)養(yǎng)角度而言，圍手術(shù)期治療要點(diǎn)包括：將營(yíng)養(yǎng)整合入患者整體管理防備長(zhǎng)時(shí)間術(shù)前禁食術(shù)后盡早重新建立經(jīng)口飼養(yǎng)一旦營(yíng)養(yǎng)風(fēng)險(xiǎn)變得明顯，早期開(kāi)始營(yíng)養(yǎng)療法代謝控制，比方血糖減少加重應(yīng)激相關(guān)分解代謝或影響胃腸功能的因素縮短用于術(shù)后呼吸機(jī)管理的麻醉藥物使用時(shí)間早期活動(dòng)以促進(jìn)蛋白質(zhì)合成和肌肉功能恢復(fù)縮寫(xiě)B(tài)M：生物醫(yī)學(xué)終點(diǎn)GPP：優(yōu)異實(shí)踐要點(diǎn)。依照指南擬定小組臨床經(jīng)驗(yàn)介紹的最正的確踐方法。HE：醫(yī)療衛(wèi)生經(jīng)濟(jì)終點(diǎn)IE：整合傳統(tǒng)終點(diǎn)與患者報(bào)告終點(diǎn)QL：生活質(zhì)量TF：管飼該指南共提出37項(xiàng)臨床實(shí)踐介紹建議：對(duì)大多數(shù)患者從子夜開(kāi)始術(shù)前禁食是不用要的。被認(rèn)為無(wú)任何誤吸風(fēng)險(xiǎn)的手術(shù)患者在麻醉前兩個(gè)小時(shí)應(yīng)喝清流質(zhì)。麻醉前六小時(shí)前應(yīng)贊成進(jìn)食固體食品（BM、IE、QL）。介紹等級(jí)：A，高度共識(shí)（97%贊成）為了減少?lài)g(shù)期不適癥狀包括憂(yōu)愁，前一天夜晚和術(shù)前兩小時(shí)應(yīng)恩賜經(jīng)口進(jìn)食碳水化合物辦理（而非夜間禁食）（B，QL）。為改進(jìn)術(shù)后胰島素抵抗和縮短住院時(shí)間，對(duì)大手術(shù)患者可考慮術(shù)前使用碳水化合物（0，BM、HE）。介紹等級(jí)：A/B，高度共識(shí)（100%贊成）在完成過(guò)程中由工作小組依照最新薈萃解析下調(diào)等級(jí)（工作小組內(nèi)成員100%贊成）一般情況下，術(shù)后經(jīng)口營(yíng)養(yǎng)攝入應(yīng)連續(xù)不中斷（BM、IE）。介紹等級(jí)：A，高度共識(shí)（90%贊成）建議依照個(gè)人耐受性和推行的手術(shù)種類(lèi)來(lái)調(diào)整經(jīng)口攝入，特別關(guān)注老年患者。介紹等級(jí)：GPP，高度共識(shí)（100%贊成）大多數(shù)患者應(yīng)在術(shù)后數(shù)小時(shí)內(nèi)開(kāi)始經(jīng)口進(jìn)食清流質(zhì)。介紹等級(jí)：A，高度共識(shí)（100%贊成）建議在大手術(shù)前后評(píng)定營(yíng)養(yǎng)情況。介紹等級(jí)：GPP，高度共識(shí)（100%贊成）營(yíng)養(yǎng)不良患者和存在營(yíng)養(yǎng)風(fēng)險(xiǎn)的患者有指征進(jìn)行圍手術(shù)期營(yíng)養(yǎng)療法。若是預(yù)計(jì)患者在圍手術(shù)期不能夠進(jìn)食高出5天，也應(yīng)啟動(dòng)圍手術(shù)期營(yíng)養(yǎng)療法。預(yù)計(jì)患者經(jīng)口攝入少，不能夠保持介紹攝入量的50%以上高出7天也是指征。在這些情況下，建議馬上恩賜營(yíng)養(yǎng)療法（首選腸內(nèi)路子ONS或TF）。介紹等級(jí)：GPP，高度共識(shí)（92%贊成）若是能量和營(yíng)養(yǎng)需求不能夠僅經(jīng)過(guò)經(jīng)口和腸道攝入滿(mǎn)足（＜能量需求的50%）超過(guò)7天，建議腸內(nèi)聯(lián)合腸外營(yíng)養(yǎng)（GPP）。倘如有營(yíng)養(yǎng)療法指征，但有腸內(nèi)營(yíng)養(yǎng)禁忌證如腸堵塞（A），應(yīng)趕忙恩賜腸外營(yíng)養(yǎng)（BM）。介紹等級(jí)：GPP/A，高度共識(shí)（100%贊成）對(duì)使用腸外營(yíng)養(yǎng)，應(yīng)首選全合一（三腔袋或藥房配制），而非多瓶輸注系統(tǒng)（BM、HE）。介紹等級(jí)：B，高度共識(shí)（100%贊成）介紹按標(biāo)準(zhǔn)化操作流程（SOP）進(jìn)行營(yíng)養(yǎng)支持，以保證有效的營(yíng)養(yǎng)支持療法。介紹等級(jí)：GPP，高度共識(shí)（100%贊成）對(duì)因腸內(nèi)飼養(yǎng)不足而需要專(zhuān)用PN的患者可考慮靜脈補(bǔ)充谷氨酰胺（0，BM、HE）。介紹等級(jí)B，共識(shí)（76%贊成），在完成過(guò)程中由工作小組依照近來(lái)的PRCT下調(diào)等級(jí)（工作小組內(nèi)成員100%贊成）僅對(duì)因腸內(nèi)飼養(yǎng)不足而需要腸外營(yíng)養(yǎng)的患者應(yīng)試慮術(shù)后腸外營(yíng)養(yǎng)包括使用ω-3脂肪酸（BM、HE）。介紹等級(jí)：B，大多數(shù)贊成（65%贊成）對(duì)接受癌癥大手術(shù)營(yíng)養(yǎng)不良的患者應(yīng)在圍手術(shù)期或最少術(shù)后使用富含免疫營(yíng)養(yǎng)素（精氨酸、ω-3脂肪酸、核苷酸）的特定配方（B，BM、HE）。目前沒(méi)有明確的憑據(jù)表示在圍手術(shù)期使用這些富含免疫營(yíng)養(yǎng)素的配方優(yōu)于標(biāo)準(zhǔn)的口服營(yíng)養(yǎng)補(bǔ)充劑。介紹等級(jí)：B/0，共識(shí)（89%贊成）有嚴(yán)重營(yíng)養(yǎng)風(fēng)險(xiǎn)的患者應(yīng)在大手術(shù)前接受營(yíng)養(yǎng)療法（A），即使手術(shù)，包括那些癌癥，必定推遲（BM）。這個(gè)時(shí)間為7～14天是合適的。介紹等級(jí)：A/0，高度共識(shí)（95%贊成）只要可行，應(yīng)首選經(jīng)口/腸內(nèi)路子（A，BM、HE、QL）。介紹等級(jí)：A，高度共識(shí)（100%贊成）當(dāng)患者從正常的食品中獲取的能量不能夠滿(mǎn)足需求，建議激勵(lì)這些患者術(shù)前采用口服營(yíng)養(yǎng)補(bǔ)充劑，無(wú)論他們的營(yíng)養(yǎng)情況如何。介紹等級(jí)：GPP，共識(shí)（86%贊成）術(shù)前對(duì)付所有營(yíng)養(yǎng)不良的癌癥患者和進(jìn)行腹部大手術(shù)的高風(fēng)險(xiǎn)患者恩賜口服營(yíng)養(yǎng)補(bǔ)充劑（BM、HE）?；技∪鉁p少癥的老年人是一群特其他高風(fēng)險(xiǎn)患者。介紹等級(jí)：A，高度共識(shí)（97%贊成）免疫調(diào)治型口服營(yíng)養(yǎng)補(bǔ)充劑包括精氨酸、ω-3脂肪酸和核苷酸可首選（0，BM、HE），術(shù)前使用5～7天（GPP）。介紹等級(jí)：0/GPP，大多數(shù)贊成，64%贊成術(shù)前腸內(nèi)營(yíng)養(yǎng)/口服營(yíng)養(yǎng)補(bǔ)充劑應(yīng)在住院前使用，以防備不用要的住院治療和降低院內(nèi)感染的風(fēng)險(xiǎn)（BM、HE、QL）。介紹等級(jí)：GPP，高度共識(shí)（91%贊成）20.術(shù)前PN只用于營(yíng)養(yǎng)不良患者或存在嚴(yán)重營(yíng)養(yǎng)風(fēng)險(xiǎn)而能量需求不能夠經(jīng)過(guò)EN完好滿(mǎn)足的患者（A，BM）。建議使用7～14天。介紹等級(jí)：A/0，高度共識(shí)（100%贊成）對(duì)不能夠早期開(kāi)始經(jīng)口營(yíng)養(yǎng)攝入、經(jīng)口攝入不足（＜50%）高出7天的患者應(yīng)盡早啟動(dòng)TF（24小時(shí)內(nèi)）。特別高風(fēng)險(xiǎn)人群包括：接受頭頸部或胃腸癌癥大手術(shù)的患者（A，BM）嚴(yán)重創(chuàng)傷包括顱腦傷害的患者（A，BM）手術(shù)時(shí)有明顯營(yíng)養(yǎng)不良的患者（A，BM，GPP）介紹等級(jí)：A/GPP，高度共識(shí)（97%贊成）對(duì)大多數(shù)患者，標(biāo)準(zhǔn)整蛋白配方是合適的。為防備因技術(shù)原因堵管和感染風(fēng)險(xiǎn)，一般不建議使用廚房制備的飲食（勻漿膳）進(jìn)行TF。介紹等級(jí)：GPP，高度共識(shí)（94%贊成）至于營(yíng)養(yǎng)不良患者的特別方面，對(duì)所有接受上消化道和胰腺大手術(shù)患者進(jìn)行TF應(yīng)試慮放置鼻空腸管（NJ）或行針刺導(dǎo)管空腸造口術(shù)（NCJ，BM）。介紹等級(jí)：B，高度共識(shí)（95%贊成）如有TF指征，應(yīng)在術(shù)后24小時(shí)內(nèi)啟動(dòng)（BM）。介紹等級(jí)：A，高度共識(shí)（91%贊成）建議以較慢的輸注速率開(kāi)始TF（如10～最大20ml/h），由于腸道耐受性有限，增加輸注速率要謹(jǐn)慎、個(gè)體化。達(dá)到目標(biāo)攝入量的時(shí)間差別會(huì)很大，可能需要5～7天。介紹等級(jí)：GPP，共識(shí)（85%贊成）若是必定長(zhǎng)遠(yuǎn)TF（＞4周），如重癥顱腦傷害，建議經(jīng)皮置管（如經(jīng)皮內(nèi)鏡下胃造口—PEG）。介紹等級(jí)：GPP，高度共識(shí)（94%贊成）如必要，在住院時(shí)期如期評(píng)定營(yíng)養(yǎng)情況，建議圍手術(shù)期接受營(yíng)養(yǎng)療法和經(jīng)過(guò)經(jīng)口路子仍不能夠滿(mǎn)足能量需求的患者出院后連續(xù)營(yíng)養(yǎng)療法包括合理的飲食指導(dǎo)。介紹等級(jí)：GPP，高度共識(shí)（97%贊成）營(yíng)養(yǎng)不良是影響移植后預(yù)后的主要因素，因此建議對(duì)營(yíng)養(yǎng)情況進(jìn)行監(jiān)測(cè)。對(duì)營(yíng)養(yǎng)不良患者，建議恩賜額外的口服營(yíng)養(yǎng)補(bǔ)充劑甚至TF。介紹等級(jí)：GPP，高度共識(shí)（100%贊成）在同等待移植的患者進(jìn)行監(jiān)測(cè)時(shí)，必定如期評(píng)定營(yíng)養(yǎng)情況和恩賜合理的飲食指導(dǎo)建議。介紹等級(jí)：GPP，高度共識(shí)（100%贊成）對(duì)活體供者和受者的介紹建議與腹部大手術(shù)患者相同。介紹等級(jí)：GPP，高度共識(shí)（97%贊成）心臟、肺、肝、胰、腎移植術(shù)后，建議在24小時(shí)內(nèi)盡早攝入正常食品或進(jìn)行腸內(nèi)營(yíng)養(yǎng)。介紹等級(jí)：GPP，高度共識(shí)（100%贊成）即使在小腸移植后，腸內(nèi)營(yíng)養(yǎng)也可盡早啟動(dòng)，但在第一周內(nèi)加量應(yīng)特別小心。介紹等級(jí)：GPP，高度共識(shí)（93%贊成）必要時(shí)應(yīng)腸內(nèi)聯(lián)合腸外營(yíng)養(yǎng)。建議對(duì)所有移植患者進(jìn)行長(zhǎng)遠(yuǎn)營(yíng)養(yǎng)監(jiān)測(cè)和合理的飲食指導(dǎo)。介紹等級(jí)：GPP，高度共識(shí)（100%贊成）減肥手術(shù)后建議早期經(jīng)口攝入。介紹等級(jí)：0，高度共識(shí)（100%贊成）簡(jiǎn)單的減肥手術(shù)不需要腸外營(yíng)養(yǎng)。介紹等級(jí)：0，高度共識(shí)（100%贊成）萬(wàn)一出現(xiàn)較大并發(fā)癥需要再次開(kāi)腹手術(shù)，可考慮使用鼻空腸管/針刺導(dǎo)管空腸造口術(shù)。介紹等級(jí)：0，共識(shí)（87%贊成）更多的介紹建議與那些接受腹部大手術(shù)的患者相同。介紹等級(jí)：0，高度共識(shí)（94%贊成）ClinNutr.2017Jun;36(3):623-650.ESPENguideline:Clinicalnutritioninsurgery.WeimannA,BragaM,CarliF,HigashiguchiT,HübnerM,KlekS,LavianoA,LjungqvistO,LoboDN,MartindaleR,WaitzbergDL,BischoffSC,SingerP.KlinikumSt.Georg,Leipzig,Germany;SanRaffaeleHospital,Milan,Italy;McGillUniversity,MontrealGeneralHospital,Montreal,Canada;FujitaHealthUniversity,Toyoake,Aichi,Japan;CentreHospitalierUniversitaireVaudois(CHUV),Lausanne,Switzerland;StanleyDudrick'sMemorialHospital,Skawina,Krakau,Poland;Universita"LaSapienza"Roma,Roma,Italy;OrebroUniversity,Orebro,Sweden;NottinghamUniversityHospitalsandUniversityofNottingham,Queen'sMedicalCentre,Nottingham,UK;OregonHealth&ScienceUniversity,Portland,OR,USA;UniversityofSaoPaulo,SaoPaulo,Brazil;UniversitatHohenheim,Stuttgart,Germany;RabinMedicalCenter,BeilinsonHospital,PetahTikva,Israel.Earlyoralfeedingisthepreferredmodeofnutritionforsurgicalpatients.Avoidanceofanynutritionaltherapybearstheriskofunderfeedingduringthepostoperativecourseaftermajorsurgery.Consideringthatmalnutritionandunderfeedingareriskfactorsforpostoperativecomplications,earlyenteralfeedingisespeciallyrelevantforanysurgicalpatientatnutritionalrisk,especiallyforthoseundergoinguppergastrointestinalsurgery.ThefocusofthisguidelineistocovernutritionalaspectsoftheEnhancedRecoveryAfterSurgery(ERAS)conceptandthespecialnutritionalneedsofpatientsundergoingmajorsurgery,e.g.forcancer,andofthosedevelopingseverecomplicationsdespitebestperioperativecare.Fromametabolicandnutritionalpointofview,thekeyaspectsofperioperativecareinclude:integrationofnutritionintotheoverallmanagementofthepatientavoidanceoflongperiodsofpreoperativefastingre-establishmentoforalfeedingasearlyaspossibleaftersurgerystartofnutritionaltherapyearly,assoonasanutritionalriskbecomesapparentreductionoffactorswhichexacerbatestress-relatedcatabolismorimpairgastrointestinalfunctionminimizedtimeonparalyticagentsforventilatormanagementinthepostoperativeperiodearlymobilisationtofacilitateproteinsynthesisandmusclefunctionTheguidelinepresents37recommendationsforclinicalpractice.BM:biomedicalendpointsGPP:Goodpracticepoints.RecommendedbestpracticebasedontheclinicalexperienceoftheguidelinedevelopmentgroupHE:healthcareeconomyendpointIE:integrationofclassicalandpatient-reportedendpointsQL:qualityoflifeTF:tubefeedingPreoperativefastingfrommidnightisunnecessaryinmostpatients.Patientsundergoingsurgery,whoareconsideredtohavenospecificriskofaspiration,shalldrinkclearfluidsuntiltwohoursbeforeanaesthesia.Solidsshallbealloweduntilsixhoursbeforeanaesthesia(BM,IE,QL).GradeofrecommendationA-strongconsensus(97%agreement)Inordertoreduceperioperativediscomfortincludinganxietyoralpreoperativecarbohydratetreatment(insteadofovernightfasting)thenightbeforeandtwohoursbeforesurgeryshouldbeadministered(B)(QL).Toimpactpostoperativeinsulinresistanceandhospitallengthofstay,preoperativecarbohydratescanbeconsideredinpatientsundergoingmajorsurgery(0)(BM,HE).ConsensusConference:GradeofrecommendationA/B-strongconsensus(100%agreement)-downgradedbytheworkinggroupduringthefinalizationprocessaccordingtotheveryrecentmeta-analysis(with100%agreementwithintheworkinggroupmembers)Ingeneral,oralnutritionalintakeshallbecontinuedaftersurgerywithoutinterruption(BM,IE).GradeofrecommendationA-strongconsensus(90%agreement)Itisrecommendedtoadaptoralintakeaccordingtoindividualtoleranceandtothetypeofsurgerycarriedoutwithspecialcautiontoelderlypatients.GradeofrecommendationGPP-strongconsensus(100%agreement)Oralintake,includingclearliquids,shallbeinitiatedwithinhoursaftersurgeryinmostpatients.GradeofrecommendationA-strongconsensus(100%agreement)Itisrecommendedtoassessthenutritionalstatusbeforeandaftermajorsurgery.GradeofrecommendationGPP-strongconsensus(100%agreement)Perioperativenutritionaltherapyisindicatedinpatientswithmalnutritionandthoseatnutritionalrisk.Perioperativenutritionaltherapyshouldalsobeinitiated,ifitisanticipatedthatthepatientwillbeunabletoeatformorethanfivedaysperioperatively.Itisalsoindicatedinpatientsexpectedtohaveloworalintakeandwhocannotmaintainabove50%ofrecommendedintakeformorethansevendays.Inthesesituations,itisrecommendedtoinitiatenutritionaltherapy(preferablybytheenteralroute-ONS-TF)withoutdelay.GradeofrecommendationGPP-strongconsensus(92%agreement)Iftheenergyandnutrientrequirementscannotbemetbyoralandenteralintakealone(<50%ofcaloricrequirement)formorethansevendays,acombinationofenteralandparenteralnutritionisrecommended(GPP).Parenteralnutritionshallbeadministeredassoonaspossibleifnutritiontherapyisindicatedandthereisacontraindicationforenteralnutrition,suchasinintestinalobstruction(A)(BM).GradeofrecommendationGPP/A-strongconsensus(100%agreement)Foradministrationofparenteralnutritionanall-in-one(three-chamberbagorpharmacyprepared)shouldbepreferredinsteadofmultibottlesystem(BM,HE).GradeofrecommendationB-strongconsensus(100%agreement)Standardisedoperatingprocedures(SOP)fornutritionalsupportarerecommendedtosecureaneffectivenutritionalsupporttherapy.GradeofrecommendationGPP-strongconsensus(100%agreement)Parenteralglutaminesupplementationmaybeconsideredinpatientswhocannotbefedadequatelyenterallyand,therefore,requireexclusivePN(0)(BM,HE).ConsensusConference:GradeofrecommendationB-consensus(76%agreement)-downgradedbytheworkinggroupduringthefinalizationprocessaccordingtotherecentPRCT(with100%agreementwithintheworkinggroupmembers).Postoperativeparenteralnutritionincludingomega-3-fattyacidsshouldbeconsideredonlyinpatientswhocannotbeadequatelyfedenterallyand,therefore,requireparenteralnutrition(BM,HE).GradeofrecommendationB-majorityagreement(65%agreement)Peri-oratleastpostoperativeadministrationofspecificformulaenrichedwithimmunonutrients(arginine,omega-3-fattyacids,ribonucleotides)shouldbegiveninmalnourishedpatientsundergoingmajorcancersurgery(B)(BM,HE).Thereiscurrentlynoclearevidencefortheuseoftheseformulaeenrichedwithimmunonutrientsvs.standardoralnutritionalsupplementsexclusivelyinthepreoperativeperiod.GradeofrecommendationB/0-consensus(89%agreement)Patientswithseverenutritionalriskshallreceivenutritionaltherapypriortomajorsurgery(A)evenifoperationsincludingthoseforcancerhavetobedelayed(BM).Aperiodof7-14daysmaybeappropriate.GradeofrecommendationA/0-strongconsensus(95%agreement)Wheneverfeasible,theoral/enteralrouteshallbepreferred(A)(BM,HE,QL).GradeofrecommendationA-strongconsensus(100%agreement)Whenpatientsdonotmeettheirenergyneedsfromnormalfooditisrecommendedtoencouragethesepatientstotakeoralnutritionalsupplementsduringthepreoperativeperiodunrelatedtotheirnutritionalstatus.GradeofrecommendationGPP-consensus(86%agreement)Preoperatively,oralnutritionalsupplementsshallbegiventoallmalnourishedcancerandhigh-riskpatientsundergoingmajorabdominalsurgery(BM,HE).Aspecialgroupofhigh-riskpatientsaretheelderlypeoplewithsarcopenia.GradeofrecommendationA-strongconsensus(97%agreement)Immunemodulatingoralnutritionalsupplementsincludingarginine,omega-3fattyacidsandnucleotidescanbepreferred(0)(BM,HE)andadministeredforfivetosevendayspreoperatively(GPP).Gradeofrecommendation0/GPP-majorityagreement,64%agreementPreoperativeenteralnutrition/oralnutritionalsupplementsshouldpreferablybeadministeredpriortohospitaladmissiontoavoidunnecessaryhospitalizationandtolowertheriskofnosocomialinfections(BM,HE,QL).GradeofrecommendationGPP-strongconsensus(91%agreement)PreoperativePNshallbeadministeredonlyinpatientswithmalnutritionorseverenutritionalriskwhereenergyrequirementcannotbeadequatelymetbyEN(A)(BM).Aperiodof7-14daysisrecommended.GradeofrecommendationA/0-strongconsensus(100%agreement)Earlytubefeeding(within24h)shallbeinitiatedinpatientsinwhomearlyoralnutritioncannotbestarted,andinwhomoralintakewillbeinadequate(<50%)formorethan7days.Specialriskgroupsare:patientsundergoingmajorheadandneckorgastrointestinalsurgeryforcancer(A)(BM)patientswithseveretraumaincludingbraininjury(A)(BM)patientswithobviousmalnutritionatthetimeofsurgery(A)(BM)(GPP).GradeofrecommendationA/GPP-strongconsensus(97%agreement)Inmostpatients,astandardwholeproteinformulaisappropriate.Fortechnicalreasonswithtubeclotggingandtheriskofinfectiontheuseofkitchen-made(blenderized)dietsfortubefeedingisnotrecommendedingeneral.GradeofrecommendationGPP-strongconsensus(94%agreement)Withspecialregardtomalnourishedpatients,placementofanasojejunaltube(NJ)orneedlecatheterjejunostomy(NCJ)shouldbeconsideredforallcandidatesfortubefeedingundergoingmajoruppergastrointestinalandpancreaticsurgery(BM).GradeofrecommendationB-strongconsensus(95%agreement)Iftubefeedingisindicated,itshallbeinitiatedwithin24haftersurgery(BM).GradeofrecommendationA-strongconsensus(91%agreement)ml/h)andtoincreasethefeedingratecarefullyandindividuallyduetolimitedintestinaltolerance.Thetimetoreachthetargetintakecanbeverydifferent,andmaytakefivetosevendays.GradeofrecommendationGPP-consensus(85%agreement)IflongtermTF(>4weeks)isnecessary,e.g.insevereheadinjury,placementofapercutaneoustube(e.g.percutaneousendoscopicgastrostomy-PEG)isrecommended.GradeofrecommendationGPP-strongconsensus(94%agreement)Regularreassessmentofnutritionalstatusduringthestayinhospitaland,ifnecessary,continuationofnutritiontherapyincludingqualifieddietarycounsellingafterdischarge,isadvisedforpatientswhohavereceivednutritiontherapyperioperativelyandstilldonotcoverappropriatelytheirenergyrequirementsviatheoralroute.GradeofrecommendationGPP-strongconsensus(97%agreement)Malnutritionisamajorfactorinfluencingoutcomeaftertransplantation,somonitoringofthenutritionalstatusisrecommended.Inmalnutrition,additionaloralnutritionalsupplementsoreventubefeedingisadvised.GradeofrecommendationGPP-strongconsensus(100%agreement)Regularassessmentofnutritionalstatusandqualifieddietarycounsellingshallberequiredwhilemonitoringpatientsonthewaitinglistbeforetransplantation.Gradeofre