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Cancer‐related malnutrition is multifactorial, including anorexia, nausea, vomiting, and metabolic disorders. It is not uncommon in patients undergoing major abdominal surgery. Although there is a lack of a standardized definition, it is well known that malnutrition is a significant risk factor of postoperative complications. Nutritional status can be measured using several tools. The gold standard for the American Society for Parenteral and Enteral Nutrition (ASPEN) is the Subjective Global Assessment (SGA), based on performance status and physical examination. It is widely used, but the main disadvantage is the high interobserver variability [19]. In 2003, the European Society of Parenteral and Enteral Nutrition (ESPEN) adopted Nutritional Risk Screening 2002 (NRS‐2002) to screen patients for malnutrition in the hospital. NRS‐2002 is based on oral food intake, weight loss, patient’s age, body mass index (BMI), and severity of underlying disease (Table 5.1) [4].

According to the ESPEN guidelines, a minimum of seven days of preoperative nutritional support that provides at least 10 kcal/kg/day is considered adequate for patients who are nutritionally at risk (NRS score at least 3) [4]. Oral nutrition support with a standard whole protein formula enriched with immune modulating substrates (arginine, ɷ‐3 fatty acids, and nucleotides) is strongly recommended [20]. Whenever feasible, enteral feeding should be preferred to parenteral nutrition [21]. Combination with parenteral nutrition may be considered in patients in whom 60% of caloric requirement cannot be achieved with the enteral route.

Table 5.1 Nutritional Risk Screening (based on NRS‐2002) [4].

	Impaired nutritional status	Severity of disease
Absent – Score 0	Normal nutritional status	Absent – Score 0	Normal nutritional requirements
Mild – Score 1	Weight loss > 5% in three months or food intake below 50–75% of normal requirement in preceding week	Mild – Score 1	Chronic patients, in particular with acute complications: cirrhosis, chronic obstructive pulmonary disease (COPD), chronic hemodialysis, diabetes, oncology
Moderate – Score 2	Weight loss > 5% in two months or BMI 18.5–20.5 plus impaired general condition or food intake 25–60% of normal requirement in preceding week	Moderate – Score 2	Major abdominal surgery, severe pneumonia, hematologic malignancy
Severe – Score 3	Weight loss > 5% in one month (> 15% in three months) or BMI < 18.5 plus impaired general condition or food intake 0–25% of normal requirement in preceding week	Severe – Score 3	Intensive care patients (APACHE > 10)
Age	If ≥ 70 years: add 1 to total score above	= Age‐adjusted total score
Score ≥ 3: the patient is nutritionally at‐risk and a nutritional care plan is initiated
Score < 3: weekly rescreening of the patient. If the patient, for instance, is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status