Nutrition care pathway for bowel cancer surgery patients

The intervention is a structured perioperative nutrition care pathway for patients undergoing colorectal cancer surgery at Christchurch Hospital, New Zealand, which is not currently part of standard care. The pathway includes patient and family/caregiver education, systematic malnutrition screening, personalised nutrition prehabilitation, and post-discharge nutrition follow-up. The intervention is informed by evidence-based recommendations from the European Society for Clinical Nutrition and Metabolism (ESPEN) 2025 Guideline on Clinical Nutrition in Surgery, Enhanced Recovery After Surgery (ERAS) Society recommendations for elective colorectal surgery, the Clinical Pathway for Colorectal Surgery, and Enhanced Recovery Canada 2023 guidelines. The pathway includes repeated malnutrition screening using five validated tools (Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), Nutrition Risk Screening (NRS)-2002, Perioperative Nutrition Screen (PONS), and Patient-Generated Subjective Global Assessment (PG-SGA)) applied across the perioperative period. The Subjective Global Assessment (SGA), a semi-gold standard tool for diagnosing malnutrition, will be used as the reference assessment. Patients identified as being at moderate or high nutrition risk on any of the administered screening tools will undergo a comprehensive SGA assessment conducted by the research student (overseas registered dietitian) under the supervision of a New Zealand registered dietitian. Patients are stratified according to nutrition risk. Patients at low risk will receive written nutrition education resources to optimise perioperative nutrition status and dietary intake. Existing peer review nutrition education materials from different sources will be used and combined to create a tailored and evidence-based resource for this study. The written education resource will cover nutritional therapy, postoperative dietary progression, high-protein food choices, oral nutrition supplements (ONS), and nutrition considerations for patients with a stoma. Patients are also educated on self-monitoring of key nutritional indicators to support active participation in recovery. Patients identified as being at moderate or high nutrition risk receive the same written education resources plus an individualised nutrition care plan, including high-calorie, high-protein dietary counselling, delivered in person, and receive approximately 600 kcal/day from oral nutrition supplements where clinically indicated. Enteral nutrition may be recommended if required. Patients prescribed ONS will be asked to complete an adherence log. Patients identified as severely malnourished (SGA-C) will be referred to their treating colorectal surgeon and Christchurch Hospital clinical dietitians for further nutrition management. The intervention is delivered across the perioperative period, including preoperative outpatient care, during neoadjuvant chemotherapy or radiotherapy where applicable, after completion of neoadjuvant treatment where applicable, and post-discharge follow-up approximately 2–3 weeks after hospital discharge. During inpatient admission, patients continue to receive standard Christchurch Hospital nutrition care. Abnormal nutrition-related findings identified during the study will be communicated to the treating multidisciplinary team for clinical follow-up. The intervention is delivered by registered dietitians through face-to-face consultations integrated into routine clinical appointments. Study visits are conducted individually and typically last 45–60 minutes. The total duration of the study will average 2 to 4 months, depending on if participant is having surgery directly or having chemotherapy/radiotherapy prior to surgery. All assessments take place at Christchurch Hospital and are scheduled to coincide with routine clinical appointments where possible. Nutrition care is individualised according to nutrition risk, clinical status, and treatment pathway. Intervention adherence and fidelity will be assessed through review of screening completion, dietetic documentation, ONS adherence logs, and follow-up attendance records by the research team.