The need for a more targeted approach reflects the complexity of pancreatic cancer care. Before surgery, patients may have reduced appetite, biliary obstruction, diabetes or prediabetes, treatment-related symptoms, inflammation and physical deconditioning. After pancreaticoduodenectomy, altered anatomy and reduced pancreatic function can further impair digestion, while a major operation and its complications can increase metabolic stress. A patient may lose weight despite taking oral supplements if pancreatic enzyme replacement is incorrectly prescribed, maintain body weight while becoming progressively weaker, or consume an adequate prescribed amount of food while remaining catabolic because of infection or progressive disease. These mechanisms are not interchangeable, so automatically increasing calories after a positive screen may address a measurement rather than the underlying process.

The proposed framework operates within the established Nutrition Care Process rather than replacing it. Four overlapping domains organize assessment and prioritization: muscle loss with functional decline; pancreatic exocrine insufficiency and impaired digestion; inflammatory and catabolic burden; and glycemic instability associated with pancreatic endocrine insufficiency. The domains are deliberately different in kind. Muscle loss is a phenotype with functional consequences, exocrine insufficiency is a digestive mechanism, inflammation describes a pathophysiological setting, and glycemic instability is a metabolic management problem. Their value lies in connecting findings to clinical decisions rather than in creating a new taxonomy. Intake and symptom burden run across all four because they can initiate, intensify or conceal problems in each domain.

Prioritization is time-dependent and does not exclude the other domains. Clinicians are encouraged to ask whether an abnormality requires an immediate management change, whether a modifiable factor can be addressed before the next oncologic milestone, and whether delay could compromise safety, nutritional adequacy, function or delivery of treatment. Sepsis, cholangitis, biliary obstruction, severe hypo- or hyperglycemia and major feeding failure therefore take precedence over elective optimization. When no urgent problem dominates, one or more domains can be designated as priorities while the others continue to be managed in parallel. For each priority, the clinical record should identify the intended action, the responsible clinician or team, a response measure, an escalation threshold and a reassessment date. Failure to improve, or deterioration elsewhere, should trigger a fresh prioritization rather than automatic escalation of the original treatment.

For muscle loss and functional decline, the Perspective recommends pairing clinically available CT-derived muscle measurements with a repeatable test such as handgrip strength, chair-rise performance, gait speed or a six-minute walk. The same functional measure should be repeated at diagnosis or the start of neoadjuvant therapy, before surgery and during early recovery, allowing clinicians to emphasize trajectory rather than a single result. Parallel declines in muscle quantity and function strengthen concern for progressive sarcopenia, whereas disagreement between the measures should prompt review of reversible factors such as pain, neuropathy, fatigue, inactivity, inadequate intake or treatment toxicity. Muscle change should not be the only outcome of care: the proposed response combines individualized protein-energy support with resistance-oriented prehabilitation or rehabilitation, symptom control and early mobilization. Evidence from pancreatic and hepatobiliary surgery indicates that functional improvement is feasible, although no single combined nutrition-exercise protocol has proved clearly superior, and PD-specific thresholds remain uncertain.

Pancreatic exocrine insufficiency may already be present before surgery because ductal obstruction and loss of functioning pancreatic tissue impair digestion, and it often becomes more common after resection. The reported frequency varies widely because studies use different tests and definitions, but prospective data indicate that exocrine function can deteriorate after surgery. Assessment is warranted when steatorrhea, bloating, urgency, frequent stools, postprandial discomfort, fat-soluble vitamin deficiency or weight and muscle loss occur despite apparently adequate intake. Steatorrhea may be absent if a patient has already reduced fat or total food intake. Fecal elastase can be a reasonable initial test in an appropriate setting, but its limitations after pancreatic surgery must be recognized. With typical symptoms and high pretest probability, treatment with pancreatic enzyme replacement therapy can begin while alternative causes are considered; improvement alone does not prove the diagnosis.

Persistent digestive symptoms call for a structured review rather than repeated empiric calorie escalation. Before concluding that enzyme therapy is ineffective, clinicians should check the product, lipase dose, timing with the first bites of food, coverage of snacks and adherence. Delayed gastric emptying, bile acid diarrhea, small-bowel bacterial overgrowth and other gastrointestinal disorders may coexist with exocrine insufficiency. Acid suppression may be considered in selected patients whose response remains inadequate despite correct timing and dose titration, but it cannot substitute for correcting basic prescribing or administration errors. Follow-up should examine stool pattern, meal tolerance, weight or muscle trajectory, documented micronutrient deficiencies and downstream glucose patterns, because improved absorption can change insulin requirements. The framework also identifies uncertainty over the best post-pancreaticoduodenectomy diagnostic strategy and the most appropriate enzyme-dosing algorithms after resection.

The inflammatory and catabolic domain requires clinicians to distinguish an acute, potentially reversible stressor from persistent cancer-associated cachexia. Infection, cholangitis, biliary obstruction, treatment toxicity, postoperative complications and progressive cancer can all produce rapid involuntary loss of weight or function, but their time courses and responses differ. Assessment should integrate actual intake, symptoms, disease stage, treatment phase, function and contributors such as pain, nausea, delayed gastric emptying, oral problems and low mood. C-reactive protein is contextual evidence rather than a nutritional target, and no single threshold distinguishes reversible catabolism from treatment-resistant cachexia. During an acute episode, priorities are source control, symptom treatment, limiting further nutritional deficit and maintaining protein-energy delivery as feasible. If decline persists after reversible factors have been addressed, goals shift toward preserving function, relieving symptoms, supporting treatment tolerance and achieving realistic stabilization rather than assuming that more calories alone will restore lost tissue.

Glycemic instability around surgery is likewise more complex than the presence or absence of diabetes. Pancreatic reserve, steroid exposure, infection, feeding route, nutrient absorption and insulin requirements can change rapidly. Relevant patterns include stress hyperglycemia, recurrent hypoglycemia, marked variability and new or changing insulin needs after resection. An extended or total pancreatectomy creates a greater insulin-management and hypoglycemia burden than a standard pancreaticoduodenectomy. Intensive near-normal glucose control is also not appropriate for every patient because it can increase hypoglycemia risk. Continuous glucose monitoring is not required routinely for stable people who are not receiving insulin and have little variability, but it should be considered for insulin-treated patients with recurrent or suspected nocturnal hypoglycemia, marked variability, rapidly changing needs during feeding transitions, or extensive or total pancreatic resection. Studies after total pancreatectomy show that continuous monitoring can quantify time in range and previously unrecognized low glucose, although evidence that it improves clinical outcomes remains limited.

Across these domains, nutrition and glucose care must remain connected. Restricting intake to suppress hyperglycemia can deepen an existing nutritional deficit, while failing to reduce insulin after interrupted feeding or altered absorption can precipitate hypoglycemia. Review should therefore include carbohydrate and protein-energy delivery, enzyme therapy, infection or inflammation, renal function, corticosteroids and feeding route, even when glycemia is the immediate priority. The same principle governs postoperative feeding and discharge. Early oral feeding remains appropriate for many patients, and selective rather than universal escalation of nutrition support is supported by comparative studies and a recent Cochrane review. A randomized trial has suggested that early supplemental nasojejunal feeding may reduce complication burden in nutritionally at-risk patients, but it does not justify routine tube feeding for everyone undergoing pancreaticoduodenectomy. The Perspective proposes pragmatic reviews about two and six weeks after discharge, with earlier contact for major symptoms, feeding failure, infection or severe glycemic instability, although these intervals have not been validated.

Safe use of the framework also depends on prospective evaluation, clear clinical ownership and a realistic interpretation of what nutrition care can accomplish. A pragmatic multicenter trial could compare standardized nutrition support with care in which screening leads to a domain-oriented assessment, named priority targets and a documented reassessment plan. Such a comparison would test generic support against support explicitly linked to the leading mechanism of decline, while recording what patients actually receive, including energy and protein delivery, exercise, enzyme dose and timing, symptom treatment, feeding route and glucose exposure. Outcomes should include domain-specific responses such as preserved strength or improved meal tolerance, recovery outcomes such as complication burden and unplanned healthcare use, and oncologic outcomes such as time to and completion of adjuvant chemotherapy. The authors acknowledge overlapping domains, uneven access to specialists and unvalidated thresholds and intervals. For now, the framework is a proposed clinical decision scaffold, not a diagnostic classification or a proven outcome-improving pathway. Its central claim is that a risk score should initiate closer assessment rather than end it: clinicians must determine what is driving decline, at which treatment stage, and what visible response is expected before the next cancer-treatment milestone.

Subject of Research: A proposed domain-guided framework for perioperative nutrition in patients with pancreatic ductal adenocarcinoma undergoing pancreaticoduodenectomy.

Article Title: Beyond nutritional risk scores: domain-guided perioperative nutrition in patients with pancreatic ductal adenocarcinoma undergoing pancreaticoduodenectomy

Article References: Xu, J., Yang, L., Liang, Y., Xie, X., Wang, W., Gao, L., Jia, B., Li, J., & Yan, J. (2026). Beyond nutritional risk scores: domain-guided perioperative nutrition in patients with pancreatic ductal adenocarcinoma undergoing pancreaticoduodenectomy. Frontiers in Nutrition, 13, Article 1955662. https://doi.org/10.3389/fnut.2026.1955662

Image Credits: AI Generated

DOI: 10.3389/fnut.2026.1955662

Keywords: pancreatic ductal adenocarcinoma, pancreaticoduodenectomy, perioperative nutrition, pancreatic exocrine insufficiency, cancer cachexia, sarcopenia, glycemic instability, clinical nutrition, nutrition risk screening, prehabilitation, Beyond, nutritional