Implementation of perioperative nutritional care from the ACERTO Project in patients with colorectal cancer: feasibility and benefits

ABSTRACT

Introduction:  Cancer patients are more susceptible to compromised nutritional status, especially when undergoing surgery. Minimizing the metabolic response and muscle catabolism associated with surgical trauma and accelerating postoperative recovery are objectives of advanced recovery protocols such as the Accelerated Postoperative Total Recovery Project (ACERTO). In this context, the study aimed to implement and evaluate the feasibility and benefits of perioperative nutritional care recommended by ACERTO in an oncology hospital.

Method:  Retrospective cohort study developed with adult and elderly patients with colorectal cancer undergoing laparotomy performed between 2018 and 2024. The study followed three phases: phase 1: ACERTO’s pre-implementation data; phase 2: implementation of the ACERTO Project; and phase 3: ACERTO’s post-implementation data. Demographic, clinical, surgical, and nutritional data, as well as outcomes, were collected in phases 1 and 3 and subjected to statistical analyses for comparison between the pre- and post-ACERTO phases.

Results:  275 pre-implantation and 101 post-implantation patient records were analyzed. Post-ACERTO patients were older (p=0.014), had higher body weight (p=0.002), higher BMI (p=0.012), and higher nutritional risk according to the NRS-2002 (p=0.015). Nutritional care improved after ACERTO implementation (p<0.05) and resulted in reduced postoperative IV fluids (p<0.001). Those who received less IV fluids had fewer complications (p=0.003). Also, after ACERTO implementation, those who were re-fed early (≤ 36 hours) had shorter hospital stays (p=0.006).

Conclusion:  The results showed that the implementation of the ACERTO nutritional guidelines at HCCU proved feasible and with important benefits for patients..

Keywords:
Trauma; Surgery; Nutritional Care; Perioperative Care; Immunonutrients; Cancer

RESUMO

Introdução:  Pacientes com câncer são mais suscetíveis ao comprometimento do estado nutricional, especialmente quando submetidos a cirurgias. Minimizar a resposta metabólica e o catabolismo muscular associados ao trauma cirúrgico e acelerar a recuperação pós-operatória são objetivos dos protocolos de recuperação avançada como o Projeto Aceleração da Recuperação Total Pós-operatória (ACERTO). Neste contexto, o estudo objetivou implantar e avaliar a factibilidade e os benefícios dos cuidados nutricionais perioperatórios recomendadas pelo ACERTO em um hospital oncológico.

Método:  Coorte retrospectiva desenvolvida com pacientes adultos e idosos com câncer colorretal submetidos a laparotomia realizadas entre 2018 e 2024. O estudo seguiu três fases: fase 1: dados pré-implantação do ACERTO; fase 2: implantação do Projeto ACERTO e fase 3: dados pós implantação do ACERTO. Os dados demográficos, clínicos, cirúrgicos, nutricionais e também os desfechos foram coletados nas fases 1 e 3 e submetidos à análises estatísticas para comparação entre as fases pré e pós-ACERTO.

Resultados:  Foram analisados 275 prontuários de pacientes pré- implantação e 101 pós-implantação. Os pacientes pós-ACERTO eram mais velhos (p=0,014), apresentavam maior peso corporal (p=0,002), maior IMC (p=0,012) e mais risco nutricional pela NRS-2002 (p=0,015). Os cuidados nutricionais melhoraram após implantação ACERTO (p<0,05) e resultaram em redução fluidos intravenoso (IV) no pós-operatório (p<0,001). Aqueles que receberam menos fluidos IV complicaram menos (p=0,003). Também, após a implantação do ACERTO, os realimentados precocemente (≤ 36horas) tiveram menor tempo de hospitalização (p=0,006).

Conclusão:  Os resultados mostraram que a implantação das diretrizes nutricionais do ACERTO no HCCU mostrou-se factível e com importantes benefícios aos pacientes.

Palavras-chave:
Trauma; Cirurgia; Cuidados Nutricionais; Cuidados Perioeratórios; Câncer

INTRODUCTION

Cancer patients are more susceptible to compromised nutritional status, especially when undergoing surgery^1-4. Surgical trauma triggers an immuno-inflammatory and neuroendocrine-metabolic response that produces muscle catabolism proportional to the magnitude of the stress, potentially compromising patients’ nutritional status and increasing the risk of postoperative complications⁵.

Advancements in surgical techniques (laparoscopic or robot-assisted) have been fundamental in enabling the response to surgical trauma⁶. Also, the understanding of how the body reacts to trauma has developed over decades. This knowledge has provided valuable insights into perioperative practices that were previously carried out without scientific support. Some cases have proved unnecessary or even detrimental to patient recovery, such as prolonged fasting⁷.

In this scenario, “fast-track” emerged, later termed multimodal protocols and now known as Enhanced Recovery After Surgery (ERAS), comprising a set of perioperative care measures that combine the best available evidence to minimize inflammation and its metabolic effects and accelerate postoperative recovery⁶.

In Brazil and other Latin American countries, the primary reference for ERAS protocols is the ACERTO project (Aceleração da Recuperação Total Pós-operatória-Acceleration of Full Postoperative Recovery), which comprises 12 guidelines covering the pre-, intra-, and postoperative periods. Five of these recommendations refer to nutritional care: nutritional prehabilitation (when indicated), perioperative immunonutrition, shortening the preoperative fasting period, the use of probiotics and synbiotics, and early refeeding. Recently, the ACERTO project incorporated a hospital discharge plan into its guidelines; this plan includes nutritional guidance for the post-discharge period aimed at reducing the risk of readmission⁶.

The effectiveness of the guidelines proposed by ACERTO and other perioperative care programs has been widely demonstrated. Studies^9-13 consistently reaffirm the benefits of implementing this perioperative care to minimize the inflammatory, immunological, and metabolic effects of surgical stress, reduce the risk of nutritional impairment, and accelerate postoperative recovery.

Given these positive results, this study aimed to implement and evaluate the feasibility and benefits of the perioperative nutritional care recommended by ACERTO in an oncology hospital.

METHOD

This is a retrospective cohort study that uses medical records as the data source for cancer patients who underwent colorectal surgery at the Hospital União Oeste Paranaense de Estudos e Combate ao Câncer Uopeccan (HCCU) in Cascavel, Paraná. A convenience sample was selected, consisting of all medical records of patients who had surgery, as specified in phases 1 and 3 of the study, and who met the inclusion criteria (Figure 1).

Figure 1
Study method flowchart.

Initially, the study proposal was presented to the HCCU multidisciplinary surgical team (surgeons, anesthesiologists, nutritionists, and nurses), who approved and collaborated to implement the nutritional care protocols of the ACERTO Project.

The study consisted of three phases⁸, as shown in the study methodology flowchart (Figure 1): Phase 1 - identification and analysis of routines and practices prescribed by surgeons and nutritionists before the implementation of the ACERTO Project (referred to “pre-ACERTO” in the study); Phase 2 - implementation of the nutritional care protocols recommended by the ACERTO Project at HCCU; and Phase 3 - identification and analysis of routines and practices prescribed by surgeons and nutritionists following the implementation of the ACERTO Project (referred to as “post-ACERTO”).

For statistical analysis, additional variables from the collected data (cited in Figure 1) were created: shortened preoperative fasting (defined as the prescription and recorded intake of Nutren Fresh® or Fresubin Juice^® between 2 and 4 hours before anesthesia induction); early refeeding (resumption of oral intake within 36 hours of surgery completion); use of oral nutritional supplements (ONS) (prescription and intake of any type of ONS within 30 days before or after surgery); use of immunonutrition supplements (Impact^® prescribed and consumed 5-7 days before or 5-7 days after surgery); operative time (hours); total and postoperative hospital stay duration (days); and presence of postoperative complications, classified as: a) infectious¹² pneumonia, surgical site and urinary tract infections, anastomotic or wound dehiscence, abscess, enterocutaneous fistulas, sepsis, and peritonitis; and b) general presence of any infectious¹² + non-infectious complication, such as non-functioning ostomies, acute kidney injury, acute myocardial infarction, hypovolemic shock, diabetic ketoacidosis, cardiorespiratory arrest, leg compartment syndrome requiring debridement, pulmonary thromboembolism, and pulmonary hypertension.

Statistical analyses were performed as described below to compare the pre-implementation periods (pre-ACERTO groups - phase 1) with the post-implementation period of the ACERTO Project (post-ACERTO group - phase 3). The Kolmogorov-Smirnov test was used to assess the normality of continuous data. Data were summarized as average (A) and standard deviation (±SD) if normally distributed, or as median (M) and interquartile range (IQR) if the distribution was skewed. The Chi-square test or Fisher’s exact test with Yates’ correction (n; %) was used to compare frequencies between the pre- and post-ACERTO implementation periods. Student’s t-test (M±SD) or the Mann-Whitney test (M; IQR) was used to compare the variables under study. A significance level of 5% (p≤0.05) was established. Statistical analysis was performed using the Statistical Package for the Social Sciences 20.0 software (SPSS Statistics; IBM, Armonk, NY, USA).

The study was approved by the Research Ethics Committee (CEP) of the Federal University of the Southern Frontier (UFFS), under opinion number 4.861.48 of 2021 and an amendment under opinion 6.173.266 of 2023.

RESULTS

Initially, 303 and 103 adult and elderly patients scheduled for elective colorectal surgery were eligible for inclusion in phases 1 (pre-ACERTO) and 3 (post-ACERTO), respectively. Figure 2 shows that the study ultimately analyzed the medical records of 275 patients from the pre-implementation period and 101 from the post-implementation period of the ACERTO Project.

Figura 2
Fluxograma dos pacientes elegíveis e que fizeram parte do estudo antes e depois da implantação do Projeto ACERTO..

All patients in the study received preoperative antibiotic prophylaxis. All underwent open colorectal surgery performed by the same team of surgeons and anesthesiologists, following the hospital’s surgical schedule during phases 1 and 3 of the study.

Table 1 shows that the operative time for patients in the pre-ACERTO group was one hour longer (p<0.001) than the post-ACERTO group. However, patients in the post-ACERTO group were older (p=0.014) and had higher body weight (p=0.002), higher BMI (p=0.012), and greater nutritional risk according to the NRS-2002 (p=0.015).

Table 1
Comparison of demographic data and characteristics of patients undergoing colorectal surgery before and after the implementation of the ACERTO Project.

Variables	Pre-CERTO	Post-ACERTO	p-value
Age (Mean ± SD)	60 ±13.24	63.8 ±12.41	0.014
Elderly (n; %)	148 (53.8)	64 (63.4)	0.413
Male (n; %)	144 (52.4)	57 (56.4)	0.736
Smoker (n; %)	80 (29.9)	36 (36.7)	0.423
Alcohol user (n; %)	46 (17.3)	15 (15.5)	0.853
Weight in kg (Median; IQR)	69 (59.6-81.1)	76 (65.0-87.0)	0.002
Height in meters (Median; IQR)	1.65 (1.57- 1.74)	1.68 (1.60-1.75)	0.099
BMI kg/m² (Mean ± SD)	25.7 (±4.9)	27.3 (±4.9)	0.012
Nutritional risk (n; %)	56 (27.4)	47 (49.5)	0.015
ASA score ≤ 2 (n; %)	236 (91.8)	75 (79.8)	0.499
Types of surgery (n; %)
Rectosigmoidectomy	132 (48.0)	49 (49.0)	0.919
Hemicolectomy	122 (44.4)	17 (17.0)	<0.001
Total colectomy	7 (2.5)	3 (3.0)	0.7310
Other	14 (5.1)	32 (32.0)	<0.001
Surgery time (hours - Median; IQR)	4.0 (2.53-4.54)	3 (2.25-3.45)	< 0.001

• BMI: Body Mass Index; ASA: American Society of Anesthesiologists. Results are presented as Mean (M) and standard deviation (±SD), Median (M) and interquartile range (IQR), or absolute numbers (n) and frequency (%), depending on the data distribution. Chi-square test (n; %); Student’s t-test (M±SD) or Mann-Whitney test (M; IQR).

Following the implementation of the ACERTO Project at HCCU, perioperative nutritional practices were implemented more frequently than in the pre-implementation period (p<0.05), except for nutritional screening upon hospital admission and discharge nutritional counseling. While these showed a trend toward increased implementation, the results did not reach statistical significance. Adherence rates exceeded 70% for more than 75% of the implemented practices (Table 2).

Table 2
Distribution of perioperative nutritional care provided to patients undergoing colorectal surgery before and after the implementation of the ACERTO Project.

Variables	Pre-ACERTO (n;%)	Post-ACERTO (n;%)	p-value
Pre-hospitalization nutritional screening	40 (14.5)	67 (66.3)	< 0.001
Nutritional screening during hospitalization	204 (74.2)	95 (94.1)	0.171
Preoperative ONS	73 (26.5)	74 (74.0)	< 0.001
Preoperative Impact®	42 (15.3)	72 (71.3)	< 0.001
Postoperative ONS	54 (19.8)	81 (81.0)	< 0.001
Postoperative Impact®	37 (13.5)	75 (74.3)	< 0.001
Reduction of preoperative fasting time (< 4 hours)	4 (1.5)	62 (61.4)	< 0.001
Early refeeding (within 36 hours)	152 (57.6)	91 (91.0)	0.006
Discharge instructions	176 (64.2)	88 (90.7)	0.083

• ONS: oral nutritional supplement. Results presented as absolute numbers (n) and frequency (%). Chi-square or Fisher’s exact test (n; %) with Yates’ correction.

As shown in Table 3, no significant difference was observed between the outcomes analyzed before and after the implementation of the care measures recommended by the ACERTO Project (p > 0.05).

Table 3
Comparison of postoperative outcomes among patients undergoing colorectal surgery before and after implementation of the ACERTO Project.

Variables	Pre-ACERTO	Post-CERTO	p-value
Total hospital stay (days) (M; IQR)	6 (4-7)	5 (5-7)	0,274
Postoperative hospital stay (days) (M; IQR)	4 (3-6)	4 (4-6)	0.295
Nausea and vomiting (n; %)	55 (20.0)	21 (21.8)	0.975
General complications (n; %)	89 (32.4)	38 (37.6)	0.551
Infectious complications (n; %)	49 (83.1)	29 (74.4)	0.994
Complications (2 or more) (n; %)	44 (74.6)	22 (62.9)	0.734
Readmission (n; %)	51 (18.5)	14 (14.3)	0.306
In-hospital death (n; %)	13 (4.7)	4 (4.0)	1.000
Death within 30 days of discharge (n; %)	7 (2.5)	2 (2.0)	1.000

• Results presented as Median (M) and interquartile range (IQR) or as absolute numbers (n) and frequency (%). Chi-square or Fisher’s exact test (n; %) with Yates’ correction, or Mann-Whitney test (M; IQR).

On the other hand, as shown in Table 4, post-ACERTO patients who started an early diet within 36 hours of surgery had a hospital stay 3 days shorter than those who received a diet more than 36 hours after surgery (p=0.006).

Table 4
Comparison between the initiation of early refeeding within 36 hours with fluid therapy and length of hospital stay in patients undergoing colorectal surgery following the implementation of the ACERTO Project.

Variables	Early initiation of diet within 36 hours post-operatively		p-value
	No	Yes
Total IV fluid volume (mL); M (IQR)	7490 (5510-12260)	5185 (2790-8757)	0.065
Mean IV fluids/day (mL); M±SD	1866 ± 736	1372 ± 845	0.095
IV fluid volume/kg/day;	22.70 (17.80-32.60)	16.30(8.30-27.00)	0.105
M (IQR)	22,70 (17,80-32,60)	16,30(8,30-27,00)	0,105
Postoperative hospital stay (days); (M; IQR)	7 (4.5-18.5)	4 (4-5)	0.006

• mL: milliliter; kg: kilogram. Results presented as Median (M) and interquartile range (IQR). Student’s t-test (M ± SD) or Mann-Whitney test (M; IQR).

In the postoperative period, as shown in Table 5, the volume of infused intravenous fluids was significantly lower following the implementation of the ACERTO Project (p<0.001).

Table 5
Comparison of the volume of intravenous fluids infused in patients undergoing colorectal surgery before and after the implementation of the ACERTO Project.

Variables	Pre-ACERTO	Post-ACERTO	p-value
	M (IIQ)	M (IIQ)
Total IV fluid volume (mL) PO	9170(5300-13050)	5800(3110-8922)	<0.001
Total IV fluid volume (mL) PO/day	2170(1530-2700)	1400(760 - 1925)	<0.001
Total IV fluid volume (mL) PO/weight (kg)/day	30.8(21.20-41.60)	17.3(9.50-27.50)	<0.001

• IV: intravenous; PO: postoperative; mL: milliliters; kg: kilogram. Results presented as median (M) and interquartile range (IQR). Mann-Whitney test (M; IQR).

In the post-ACERTO group, patients who received higher volumes of IV fluids had significantly more postoperative complications (p<0.01) (Table 6).

Tabela 6
Association between the presence of complications and intravenous fluid infusion in patients undergoing colorectal surgery after ACERTO implementation.

Variable	Complication		p-value
	Yes	No
Total IV fluid volume (mL)	7810	4080
M (IIQ)	(4597 -10885)	(2585-7712)	0.000
Mean IV fluids/day (mL)	1748 ± 877	1253± 808
M ±SD			0.005
Volume of IV fluids/kg/day	22.4	13.0
M (IIQ)	(16.4 -31.2)	(7.7 - 23.2)	0.003

• kg: kilogram; mL: milliliter. Results presented as Mean (M) and Standard Deviation (±SD), Median (M), and Interquartile Range (IQR). Student’s t-test (M±SD) or Mann-Whitney test (M; IQR).

DISCUSSION

The results of this study showed that the implementation of the ACERTO Project’s nutritional guidelines led to a significant improvement in pre-hospitalization nutritional screening, the prescription of oral nutritional supplements (with and without immunonutrients), the shortening of preoperative fasting times, and early postoperative refeeding (within 36 hours).

In Brazil, the first implementation of the ACERTO protocol occurred at the Júlio Muller University Hospital in Cuiabá. The results showed adherence rates of 72% for reducing the preoperative fasting period and 66.7% for early refeeding. Adherence to other ACERTO recommendations exceeded 70%. The impact of these measures led to a reduction in postoperative morbidity and a 2-day decrease in the length of hospital stay^14,15.

Other studies^12,16-18 analyzing the implementation of ERAS demonstrated benefits, even when adherence rates did not reach 100%. Significant differences have been observed with approximately 70% adherence to the recommendations made by ERAS^15,19,20.

In this study, the analysis of adherence to nutritional guidelines showed that pre-hospitalization nutritional screening increased from 14.5% in the pre-ACERTO phase to 66.3% in the post-ACERTO phase. There is a consensus among various nutrition-focused professional societies that all oncology and/or surgical patients should undergo early nutritional screening^21-24,25. Screening identifies at-risk patients, factors associated with reduced food intake, and deficits requiring regular nutritional assessment and monitoring²⁶.

The prescription of ONS increased at both evaluated time points, pre- and post-operatively, aligning with the study objectives and the recommendations of nutrition²⁵ and surgery⁶ societies. For patients at nutritional risk, the ACERTO Project advises Immediate Nutritional Intervention (INTERNUTI) for a period of 7 to 14 days before medium and major surgeries. This intervention should continue into the post-operative period until nutritional status improves²⁵.

SNOI intake was higher in the post-ACERTO group during both the preoperative and postoperative periods. Recent meta-analysis has shown the significance of this findings. Khan et al. (2023) showed that, in patients undergoing gastrointestinal tract surgery, significant reductions in infectious complications were associated with immunonutrient intake during the perioperative period, even when administered solely in the preoperative period. Furthermore, the length of hospital stay was reduced by 3.2 and 1.68 days when immunonutrition was used during the perioperative and preoperative periods, respectively¹¹. Another meta-analysis¹⁰ compared immunonutrient supplementation with standard nutritional therapy in patients with gastrointestinal or head and neck cancer and revealed a significant reduction in both total and infectious complications among patients receiving an immunonutrient-enriched diet. Subgroup analysis showed that diets containing both arginine and omega-3 were more effective in preventing total complications and reducing the length of hospital stay compared to immunonutrition regimens lacking arginine or containing only one or two ingredients.

The types of immunonutrients studied in surgical patients, arginine, omega-3, nucleotides, and glutamine stand out. They are associated with improvements in immune function, inflammation, wound healing, and DNA and RNA synthesis²⁷.

The reduction of the patient’s perioperative fasting time is an important nutritional measure recommended by the ACERTO Project and other ERAS programs. In the preoperative period, it is recommended to shorten the fast by administering clear fluids containing 12.5% dextrose, with or without a nitrogen source, between 2 and 3 hours before anesthesia induction^6,28.

In this study, the shortening of the fasting period was achieved using two products from different brands, both containing approximately 60 g of carbohydrates and 10 g of whey protein. The benefits of shortening preoperative fasting with solutions containing carbohydrates, or carbohydrates plus protein, are widely documented and include glycemic/metabolic control and increased insulin sensitivity^29-34, reduced inflammation^13,32,35, enhanced antioxidant defenses, via increased glutathione peroxidase synthesis¹³, shorter hospital stays^12,30,36,37, and improved perioperative well-being (hunger, thirst, and pain)^9,29,38.

This approach is supported by various societies given the efficacy and safety demonstrated in randomized clinical trials and meta-analyses, including the Brazilian College of Digestive Surgery (Colégio Brasileiro de Cirurgias Digestivas)⁶, the American Society of Anesthesiologists³⁹, and the Brazilian Society of Parenteral and Enteral Nutrition (Sociedade Brasileira de Nutrição Parenteral e Enteral)²⁷, among others.

Numerous studies have shown the benefits of proper preoperative nutrition; however, a multicenter investigation conducted in 16 Brazilian hospitals revealed that 46.2% of surgical patients40 experienced fasting periods longer than 12 hours. Similar findings have been reported in hospitals in other countries⁴¹. These results emphasize the need to implement the ACERTO nutritional guidelines for all surgical patients.

Regarding fasting duration, specifically in the postoperative period, early refeeding accelerates patient recovery. The presence of food and nutrients in the intestinal lumen increases the release of excitatory brain-gut peptides, motilin and gastrin, and decreases serum concentrations of inhibitory peptides, cholecystokinin and somatostatin, promoting flatulence and defecation⁴². Also, the presence of food in the intestinal lumen reduces the release of inflammatory cytokines such as interleukin-6, interleukin-8, and tumor necrosis factor-α, minimizing the inflammatory response to surgical trauma⁴³. Other observed benefits include a reduction in infectious complications^44,45 and a shorter length of hospital stay^44,45. Corroborating previous studies, our results showed that early refeeding (within 36 hours) significantly contributed to reducing the postoperative hospital stay by up to 3 days. This finding suggests that a shorter hospital stay leads to reduced hospital costs, a matter of importance for healthcare institutions, as previously observed in other studies⁴⁶.

On the other hand, prolonged postoperative fasting exacerbates deleterious effects triggered by surgical trauma, such as inflammation, protein catabolism, and insulin resistance, resulting in impaired wound healing and an increased risk of complications^5,47. The absence of nutrients in the intestinal lumen also compromises the structural and functional integrity of the mucosa^47,48. The ACERTO Project recommends a full liquid diet containing protein on the first postoperative day, whenever possible²⁷.

A reduction in intravenous fluid administration following the implementation of nutritional care protocols recommended by the ACERTO project was another significant result observed in the evaluated patients. Fluid management plays a crucial role in the postoperative recovery of surgical patients. Avoiding excessive intravenous fluid administration is just as important as preventing patient dehydration. According to the protocols, the daily volume of infused fluids should not exceed 25-30 mL/kg/day under normal conditions, and weight gain should not exceed 2.0kg^6,28.

In our study, we observed that the median volume of fluids infused during the immediate postoperative period through the fourth day of hospitalization decreased by more than 10 mL/kg of body weight per day in both the pre- and post-ACERTO groups. Specifically, the volume decreased from 30.8 mL/kg/day to 17.3 mL/kg/day. Considering only patients in the post-ACERTO group, those who received a lower volume of fluids after surgery experienced fewer complications.

Corroborating our results, a previous study observed faster recovery, a lower complication rate, a shorter hospital stay, and a lower 30-day readmission rate in patients who received balanced fluid therapy on the day of surgery⁴⁹.

In recent decades, there has been extensive research into the impact of nutritional guidelines proposed by ERAS. Although results are positive, with widely proven benefits for both patients and institutions, adherence has fallen short of expectations⁵⁰. Translating theory into practice remains a challenge, as it requires adequate staffing levels, leadership, administrative support, and multidisciplinary teams aligned with evidence-based approaches.

Despite the various challenges involved in implementing the nutritional guidelines proposed by ACERTO, the results achieved raised expectations for expanding the project to other types of surgery at HCCU and were instrumental in fostering multidisciplinary work that is more evidence-based and particularly beneficial to patients. At the same time, the implementation of protocols undoubtedly enhances the quality of the teams’ work.

The results of this study also have limitations, as it is a retrospective cohort study in which data recorded in medical records may contain some degree of inaccuracy.

CONCLUSION

The results of the current study showed that the implementation of the ACERTO Project’s nutritional guidelines in oncology hospitals is feasible. Adherence rates for all nutritional guidelines exceeded 70%. Greater adherence to early refeeding (within 36 hours) contributed to reduce the length of hospital stay. Following the implementation of ACERTO nutritional care, a significant reduction in postoperative IV fluid infusion was observed. Patients who received less IV fluid postoperatively experienced fewer postoperative complications.

REFERENCES

• ¹ Muscaritoli M, Molfino A, Orlando S, Tambaro F. Advancements of investigational agents for cancer cachexia: what clinical progress have we seen in the last 5 years? Expert Opin Investig Drugs. 2025 Nov;34(11):855-867. doi: 10.1080/13543784.2025.2588640. Epub 2025 Nov 12. PMID: 41222020.
  » https://doi.org/10.1080/13543784.2025.2588640
• ² Chen W, Yuan Q, Li X, Yao J, Yuan L, Chen X, Gao B. The role of sarcopenic obesity for the prediction of prognosis of patients with gastrointestinal cancer. Cancer Med. 2024 Jul;13(13):e7452. doi: 10.1002/cam4.7452.
  » https://doi.org/10.1002/cam4.7452
• ³ Saino Y, Kawase F, Nagano A, Ueshima J, Kobayashi H, Murotani K, Inoue T, Nagami S, Suzuki M, Maeda K. Diagnosis and prevalence of sarcopenic obesity in patients with colorectal cancer: A scoping review. Clin Nutr. 2023 Sep;42(9):1595-1601. doi: 10.1016/j.clnu.2023.06.025.
  » https://doi.org/10.1016/j.clnu.2023.06.025
• ⁴ Meza-Valderrama Y, Kawase F, Nagano A, Ueshima J, Kobayashi H, Murotani K, Inoue T, Nagami S, Suzuki M, Maeda K. Diagnosis and prevalence of sarcopenic obesity in patients with colorectal cancer: A scoping review. Clin Nutr. 2023 Sep;42(9):1595-1601. doi: 10.1016/j.clnu.2023.06.025.
  » https://doi.org/10.1016/j.clnu.2023.06.025
• ⁵ Ivascu R, Torsin LI, Hostiuc L, Nitipir C, Corneci D, Dutu M. The Surgical Stress Response and Anesthesia: A Narrative Review. J Clin Med. 2024 May 20;13(10):3017. doi: 10.3390/jcm13103017.
  » https://doi.org/10.3390/jcm13103017
• ⁶ Aguilar-Nascimento JE, Ribeiro JU, Portari-Filho PE, Salomão AB, Caporossi, C, Colleoni Neto, R., Campos ACL. Perioperative care in digestive surgery: the ERAS and ACERTO protocols - Brazilian College of Digestive Surgery Position Paper. ABCD. Arquivos Brasileiros de Cirurgia Digestiva. 2024. 37, e1794. 10.1016/j.clnu.2021.05.030
  » https://doi.org/10.1016/j.clnu.2021.05.030
• ⁷ Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008 Aug;248(2):189-98. doi: 10.1097/SLA.0b013e31817f2c1a.
  » https://doi.org/10.1097/SLA.0b013e31817f2c1a
• ⁸ Aguilar-Nascimento JE, Salomão AB, Caporossi C, Dock-Nascimento DB, Portari-Filho PE, Campos ACL, et al. ACERTO Project - 15 years changing perioperative care in Brazil. Rev Col Bras Cir.2020;48:e20202832. https://doi.org/10.1590/0100-6991e-20202832.
  » https://doi.org/10.1590/0100-6991e-20202832.
• ⁹ Wang XH, Wang ZY, Shan ZR, Wang R, Wang ZP. Effects of Preoperative Oral Carbohydrates on Recovery After Laparoscopic Cholecystectomy: A Meta-analysis of Randomized Controlled Trials. J Perianesth Nurs. 2025 Feb;40(1):169-180. doi: 10.1016/j.jopan.2024.03.007.
  » https://doi.org/10.1016/j.jopan.2024.03.007
• ¹⁰ Matsui R, Sagawa M, Sano A, Sakai M, Hiraoka SI, Tabei I...Kotani J. Impact of Perioperative Immunonutrition on Postoperative Outcomes for Patients Undergoing Head and Neck or Gastrointestinal Cancer Surgeries: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg. 2024 Mar 1;279(3):419-428. doi: 10.1097/SLA.0000000000006116.
  » https://doi.org/10.1097/SLA.0000000000006116
• ¹¹ Khan A, Wong J, Riedel B, Laing E, Beaumont A, Kong J... Heriot A. The Impact of Peri-operative Enteral Immunonutrition on Post-operative Complications in Gastrointestinal Cancer Surgery: A Meta-Analysis. Ann Surg Oncol. 2023 Jun;30(6):3619-3631. doi: 10.1245/s10434-023-13265-1.
  » https://doi.org/10.1245/s10434-023-13265-1
• ¹² Bicudo-Salomão A, Salomão RF, Cuerva MP, Martins MS, DockNascimento DB, Aguilar-Nascimento JE. Factors related to the reduction of the risk of complications in colorectal surgery within perioperative care recommended by the ACERTO protocol. Arq Bras Cir Dig. 2019;32(4):e1477. https://doi.org/10.1590/0102-672020190001e1477.
  » https://doi.org/10.1590/0102-672020190001e1477.
• ¹³ Dock-Nascimento DB, de Aguilar-Nascimento JE, Magalhaes Faria MS, Caporossi C, Slhessarenko N, Waitzberg DL. Evaluation of the effects of a preoperative 2-hour fast with maltodextrine and glutamine on insulin resistance, acute-phase response, nitrogen balance, and serum glutathione after laparoscopic cholecystectomy: a controlled randomized trial. JPEN J Parenter Enteral Nutr. 2012 Jan;36(1):43-52.
• ¹⁴ Aguilar-Nascimento JE, Colombo T, Soares MCF, Adorino IF, Anabuki NT, da Silva Filho AC..., Caporossi C. Difficulties in the implementation of multimdalprotocol in a university hospital in Brazil. World J Surg (2009) 33:S1-S268.
• ¹⁵ Aguilar-Nascimento JE, Bicudo-Salomão A, Caporossi C, Silva RM, Cardoso EA, Santos TP. ACERTO pós-operatório: avaliação dos resultados da implantação de um protocolo multidisciplinar de cuidados peri-operatórios em cirurgia geral. Rev. Col. Bras. Cir. 33 (3). Jun 2006.
• ¹⁶ Ștefănescu VC, Ionescu AM, Florea SF, Vasile MA, Bataila V, Cochior D. Breaking surgical barriers: ERAS in action in Romania. J Med Life. 2025 Mar;18(3):229-234. doi: 10.25122/jml-2025-0034.
  » https://doi.org/10.25122/jml-2025-0034.
• ¹⁷ Bel Diaz J, Barbero Mielgo M, Pérez Garnelo A, Guzmán Carranza R, García Fernández J. Analysis of protocol adherence and outcomes of an enhanced recovery program in colorectal surgery after 5 years of implementation. J Healthc Qual Res. 2025 May-Jun;40(3):101111. doi: 10.1016/j.jhqr.2024.12.010.
  » https://doi.org/10.1016/j.jhqr.2024.12.010.
• ¹⁸ Martin L, Gillis C, Atkins M, Gillam M, Sheppard C, Buhler S... Gramlich L. Implementation of an Enhanced Recovery After Surgery Program Can Change Nutrition Care Practice: A Multicenter Experience in Elective Colorectal Surgery. JPEN J Parenter Enteral Nutr. 2019 Feb;43(2):206-219. doi: 10.1002/jpen.1417.
  » https://doi.org/10.1002/jpen.1417
• ¹⁹ O'Connor GD, Taplin R, Murphy C. Assessment of pre-, peri-, and post-surgical practices for elective colorectal patients in a model 4 hospital in Ireland. Ir J Med Sci. 2024 Oct;193(5):2461-2468. doi: 10.1007/s11845-024-03731-4.
  » https://doi.org/10.1007/s11845-024-03731-4
• ²⁰ Gustafsson UO, Oppelstrup H, Thorell A, Nygren J, Ljungqvist O. Adherence to the ERAS protocol is Associated with 5-Year Survival After Colorectal Cancer Surgery: A Retrospective Cohort Study. World J Surg. 2016 Jul;40(7):1741-7. doi: 10.1007/s00268-016-3460-y.
  » https://doi.org/10.1007/s00268-016-3460-y
• ²¹ Weimann A, Bezmarevic M, Braga M, Correia MITD, Funk-Debleds P, Gianotti L, et al. ESPEN guideline on clinical nutrition in surgery - Update 2025. Clin Nutr. 2025;53:222-261. doi: 10.1016/j.clnu.2025.08.02
  » https://doi.org/10.1016/j.clnu.2025.08.02
• ²² Trujillo EB, Kadakia KC, Thomson C, Zhang FF, Livinski A, Pollard K... Spees CK. Malnutrition risk screening in adult oncology outpatients: An ASPEN systematic review and clinical recommendations. JPEN J Parenter Enteral Nutr. 2024 Nov;48(8):874-894. doi: 10.1002/jpen.2688.
  » https://doi.org/10.1002/jpen.2688
• ²³ Muscaritoli M, Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H... Bischoff SC. ESPEN practical guideline: Clinical Nutrition in cancer. Clin Nutr. 2021 May;40(5):2898-2913. doi: 10.1016/j.clnu.2021.02.005.
  » https://doi.org/10.1016/j.clnu.2021.02.005
• ²⁴ Lobo DN, Gianotti L, Adiamah A, Barazzoni R, Deutz NEP, Dhatariya K...Weimann A. Perioperative nutrition: Recommendations from the ESPEN expert group. Clin Nutr. 2020 Nov;39(11):3211-3227. doi: 10.1016/j.clnu.2020.03.038.
  » https://doi.org/10.1016/j.clnu.2020.03.038
• ²⁵ Aguilar-Nascimento JE, Salomão AB, Waitzberg DL, Dock-Nascimento DB, Correa MITD, Campos ACL, et al. ACERTO guidelines of perioperative nutritional interventions in elective general surgery. Rev Col Bras Cir. 2017;44(6):633-48. https://doi.org/10.1590/0100- 69912017006003
  » https://doi.org/10.1590/0100- 69912017006003
• ²⁶ Bauer JM, Pattwell M, Barazzoni R, Battisti NML, Soto-Perez-de-Celis E, Hamaker ME... Soubeyran P, Aapro M. Systematic nutritional screening and assessment in older patients: Rationale for its integration into oncology practice. Eur J Cancer. 2024 Sep;209:114237. doi: 10.1016/j.ejca.2024.114237.
  » https://doi.org/10.1016/j.ejca.2024.114237
• ²⁷ Tejera Pérez C, Guillín Amarelle C, Rodríguez Novo N, Lugo Rodríguez G, Mantiñán Gil B, Palmeiro Carballeira R... Martínez Olmos MÁ. Inmunonutrición, evidencias y experiencias. Nutr Hosp 2023;40(1):186-199
• ²⁸ Gustafsson UO, Rockall TA, Wexner S, How KY, Emile S, Marchuk A, Fawcett WJ, Sioson M, Riedel B, Chahal R, Balfour A, Baldini G, de Groof EJ, Romagnoli S, Coca-Martinez M, Grass F, Brindle M, Hubner M. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations 2025. Surgery. 2025 Aug;184:109397. doi: 10.1016/j.surg.2025.109397.
  » https://doi.org/10.1016/j.surg.2025.109397
• ²⁹ Lai Y, Cai Y, Ding Z, Huang C, Luo Z, Zhou Z. Effect of Preoperative Carbohydrate Loading on Postoperative Recovery of Individuals Who Have Type 2 Diabetes After Total Knee Arthroplasty: A Randomized Controlled Trial. J Arthroplasty. 2025 Mar;40(3):665-671. doi: 10.1016/j.arth.2024.09.016.
  » https://doi.org/10.1016/j.arth.2024.09.016
• ³⁰ Ricci C, Ingaldi C, Alberici L, Serbassi F, Pagano N, De Raffele E...Casadei R. Preoperative carbohydrate loading before elective abdominal surgery: A systematic review and network meta-analysis of phase II/III randomized controlled trials. Clin Nutr. 2022 Feb;41(2):313-320. doi: 10.1016/j.clnu.2021.12.016.
  » https://doi.org/10.1016/j.clnu.2021.12.016
• ³¹ Chen L, Wang N, Xie G, Wang M, Yu Y, Wang H, Fang X. The safety of preoperative carbohydrate drinks in extremely elderly patients assessed by gastric ultrasonography: a randomized controlled trial. BMC Anesthesiol. 2024 Feb 26;24(1):78. doi: 10.1186/s12871-024-02457-1.
  » https://doi.org/10.1186/s12871-024-02457-1
• ³² Carvalho CS, Silva TH, André JCS, Barros LAS, Ferreira AA, Murad LB, Peres WAF. Preoperative Fasting Abbreviation With Whey Protein Reduces the Occurrence of Postoperative Complications in Patients With Head and Neck Cancer: A Randomized Clinical Trial. Nutr Clin Pract. 2021 Jun;36(3):665-672. doi: 10.1002/ncp.10624.
  » https://doi.org/10.1002/ncp.10624
• ³³ Kotfis K, Jamiol-Milc D, Skonieczna-Zydecka K, Folwarski M, Stachowska E. The Effect of Preoperative Carbohydrate Loading on Clinical and Biochemical Outcomes after Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Trials. Nutrients. 2020 Oct 12;12(10):3105. doi: 10.3390/nu12103105.
  » https://doi.org/10.3390/nu12103105
• ³⁴ Dock-Nascimento, DB, Aguilar-Nascimento, JED, Waitzberg, DL. Ingestão de glutamina e maltodextrina duas horas no pré-operatório imediato melhora a sensibilidade à insulina pós-operatória: estudo aleatório, duplo-cego e controlado. Revista do Colégio Brasileiro de Cirurgiões. 2012 Dez; 39: 449-455.
• ³⁵ Hu Z, Liu J, Wang F. Effects of Preoperative Carbohydrate Intake on Inflammatory Markers and Clinical Outcomes in Elderly Patients Undergoing Radical Prostatectomy: A Single-Centre, Double-Blind Randomised Controlled Trial. Front Surg. 2021 Nov 18;8:744091. doi: 10.3389/fsurg.2021.744091.
  » https://doi.org/10.3389/fsurg.2021.744091
• ³⁶ Sebestyén AR, Turan C, Szemere A, Virág M, Ocskay K, Dembrovszky F... Molnár Z. Preoperative carbohydrate loading reduces length of stay after major elective, non-cardiac surgery when compared to fasting: a systematic review and meta-analysis. Sci Rep. 2025 May 31;15(1):19119. doi: 10.1038/s41598-025-00767-z.
  » https://doi.org/10.1038/s41598-025-00767-z
• ³⁷ Cheng PL, Loh EW, Chen JT, Tam KW. Effects of preoperative oral carbohydrate on postoperative discomfort in patients undergoing elective surgery: a meta-analysis of randomized controlled trials. Langenbecks Arch Surg. 2021 Jun;406(4):993-1005. doi: 10.1007/s00423-021-02110-2.
  » https://doi.org/10.1007/s00423-021-02110-2
• ³⁸ Alsharkh WS, Aljuaid M, Huda AU, Bawazir A, Alharbi A, Alharbi N. Effect of total fasting hours on the overall quality of recovery after surgery: An observational study. Saudi J Anaesth. 2023 Jul-Sep;17(3):373-377. doi: 10.4103/sja.sja_71_23.
  » https://doi.org/10.4103/sja.sja_71_23.
• ³⁹ Joshi GP, Abdelmalak BB, Weigel WA, Harbell MW, Kuo CI, Soriano SG... Domino KB. 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration-A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting. Anesthesiology. 2023 Feb 1;138(2):132-151. doi: 10.1097/ALN.0000000000004381.
  » https://doi.org/10.1097/ALN.0000000000004381
• ⁴⁰ Aguilar-Nascimento JE, de Almeida Dias AL, Dock-Nascimento DB, Correia MI, Campos AC, Portari-Filho PE, Oliveira SS. Actual preoperative fasting time in Brazilian hospitals: the BIGFAST multicenter study. Ther Clin Risk Manag. 2014 Feb 14;10:107-12. doi: 10.2147/TCRM.S56255.
  » https://doi.org/10.2147/TCRM.S56255
• ⁴¹ Adesunkanmi AO Ubom AE, Ndegbu CU, Olugbami AM, Aaron OI, Wuraola FO, Olasehinde O. Audit of Preoperative Fasting for Elective General Surgeries in the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. West Afr J Med. 2023 Aug 28;40(8):786-791.
• ⁴² Chen X, Wang P, Leng C, Sun H, Liu X, Zhang R... Z, Li Y. Early oral feeding after esophagectomy accelerated gut function recovery by regulating brain-gut peptide secretion. Surgery. 2022 Sep;172(3):919-925. doi: 10.1016/j.surg.2022.04.041.
  » https://doi.org/10.1016/j.surg.2022.04.041
• ⁴³ Sun HB, Li Y, Liu XB, Wang ZF, Zhang RX, Lerut T... Chen XK. Impact of an Early Oral Feeding Protocol on Inflammatory Cytokine Changes After Esophagectomy. Ann Thorac Surg. 2019 Mar;107(3):912-920. doi: 10.1016/j.athoracsur.2018.09.048.
  » https://doi.org/10.1016/j.athoracsur.2018.09.048
• ⁴⁴ Frizon E, Aguilar-Nascimento JED, Zanini JC, Roux MS, Schemberg BCDL, Tonello PL, Dock-Nascimento, DB. Early refeeding after colorectal cancer surgery reduces complications and length of hospital stay. ABCD. Arquivos Brasileiros de Cirurgia Digestiva. 2024; 37: e1854.
• ⁴⁵ Hao T, Liu Q, Lv X, Qiu J, Zhang HR, Jiang HP. Efficacy and safety of early oral feeding in postoperative patients with upper gastrointestinal tumor: a systematic review and meta-analysis. World J Gastrointest Surg. 2021;13(7):717-33. https://doi.org/10.4240/wjgs.v13.i7.717
  » https://doi.org/10.4240/wjgs.v13.i7.717
• ⁴⁶ Aguilar-Nascimento JE, Salomão AB, Ribeiro MRR, Silva RFD, Arruda WSC. Cost-effectiveness analysis of hernioplasties before and after the implementation of the ACERTO project. Rev Col Bras Cir. 2020;47:e20202438. Portuguese, English. doi: 10.1590/0100-6991e-20202438.
  » https://doi.org/10.1590/0100-6991e-20202438
• ⁴⁷ Ljungqvist O, Weimann A, Sandini M, Baldini G, Gianotti L. Contemporary Perioperative Nutritional Care. Annu Rev Nutr. 2024 Aug;44(1):231-255. doi: 10.1146/annurev-nutr-062222-021228.
  » https://doi.org/10.1146/annurev-nutr-062222-021228
• ⁴⁸ Kudsk K. Importance of enteral feeding in maintaining gut integrity. Techniques in Gastrointestinal Endoscopy 2001;3(1):2-8. doi: 10.1053/tgie.2001.19906.
  » https://doi.org/10.1053/tgie.2001.19906
• ⁴⁹ Pisarska-Adamczyk M, Torbicz G, Gajewska N, Malczak P, Major P, Pedziwiatr M, Wysocki M. The impact of perioperative fluid therapy on the short-term outcomes after laparoscopic colorectal cancer surgery with ERAS protocol: a prospective observational study. Sci Rep. 2023 Dec 14;13(1):22282. doi: 10.1038/s41598-023-49704-y.
  » https://doi.org/10.1038/s41598-023-49704-y
• ⁵⁰ Gonzalez MC, Gonçalves TJM, Rosenfeld VA, Orlandi SP, Portari-Filho PE, Campos ACL. Assessment of the adherence to perioperative nutritional care protocols in Brazilian hospitals: The PreopWeek study. Nutrition. 2025 Feb;130:112611. doi: 10.1016/j.nut.2024.112611. Epub 2024 Oct 23. PMID: 39549649.Clinical Nutrition, Volume 53, 222 - 261
  » https://doi.org/10.1016/j.nut.2024.112611

Data availability

Datasets related to this article will be available upon request to the corresponding author.

Funding source:

none.

Mailing address:

Eliani Frizon E-mail: [e-mail]

Conflict of interest:

no.

Editor

Daniel Cacione

Associated Editor

Phillipe Abreu

Publication Dates

• Publication in this collection
  05 Oct 2026
• Date of issue
  2026

History

• Received
  03 Feb 2026
• Accepted
  09 June 2026