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

The study, led by Katharine E. Caldwell of the Medical University of South Carolina with Dominic E. Sanford of Mayo Clinic Arizona and Natasha Leigh of Washington University in Saint Louis, examined de-identified case logs from the Fellowship Council for fellows graduating between 2014 and 2023 who pursued certification through the Americas Hepatopancreatobiliary Association (AHPBA). The cohort comprised 146 fellows from dedicated HPB programs, 55 from complex general surgical oncology (CGSO) programs, and 51 from transplant (TXP) programs. Because CGSO and TXP fellowships are all two-year programs while HPB fellowships included both one-year and two-year tracks, the researchers compared total operative experience per fellowship rather than per year, ensuring that differences in program length did not distort the comparison.

The structural differences between the pathways are central to the story. Dedicated HPB fellowships immerse trainees almost entirely in liver, pancreas, and biliary operations, although fellows may spend up to one month per year on a transplant rotation. CGSO fellows pursuing an AHPBA-certified track may spend six to ten months across their two fellowship years on HPB-focused rotations, with the remainder devoted to broader surgical oncology. TXP fellows on HPB tracks may spend only three to six months on HPB services, and the exact duration varies considerably between programs, with some centers caring for non-transplant HPB cases alongside routine liver transplant work depending on the attending surgeons’ practice patterns. These competing clinical mandates, the authors hypothesized, would translate into different case mixes by the end of training.

The data confirmed that hypothesis in striking detail. HPB fellows completed the highest average total case volume at 187.4 cases, compared with 147.2 for CGSO and 160.9 for TXP fellows. HPB fellows also logged significantly more total pancreas operations, 82.0 on average, driven largely by open pancreaticoduodenectomy, the most technically demanding standard pancreatic resection, of which they performed 35.9 compared with 28.3 in CGSO and 29.8 in TXP fellows. Total liver resection volumes were broadly comparable across the three pathways, but the composition differed: transplant fellows led in open anatomic liver resections at 35.2 cases, reflecting the vascular and hepatic expertise central to transplantation, while HPB fellows performed the most non-anatomic resections at 67.3.

The most consequential divergence, however, emerged in robotic surgery. Across all three cohorts, average robotic case volume rose nearly elevenfold over the decade, from 1.7 to 18.7 cases, a signal of how rapidly the field has pivoted toward robotic platforms. But the distribution was starkly uneven. HPB fellows averaged 12.5 robotic HPB cases, CGSO fellows 8.5, and transplant fellows just 1.0, a statistically significant gap that persisted across nearly every operation type. HPB fellows logged 4.4 robotic pancreaticoduodenectomies and 3.8 robotic distal pancreatectomies on average, compared with 0.2 and 0.6 respectively for their transplant counterparts. Robotic anatomic liver resections, at 2.1 cases in the HPB track, were more than sixty times the transplant figure of 0.03.

Those numbers matter because of what is known about learning curves in robotic HPB surgery. Published analyses suggest that surgeons need roughly 40 robotic pancreaticoduodenectomies or 30 robotic major hepatectomies to reach proficiency, with learning curve estimates for these complex operations generally falling between 30 and 50 cases. Not a single fellow in the entire ten-year series exceeded those thresholds, although several HPB-track trainees came within five cases of them. In other words, even in the highest-volume pathway, the average graduate leaves fellowship well short of the published proficiency boundary, meaning the steepest part of the learning curve must be climbed in early independent practice, often without the structured mentorship, simulation, and coaching that fellowship uniquely provides.

The authors are careful to note that the fellowship’s goal is not to produce fully mastered robotic surgeons, which requires years of practice, feedback, and failure. Rather, fellowship should supply adequate exposure, autonomy, and mentorship so that graduates can continue developing safely in their first jobs. The concern is that the observed gaps, particularly the near-total absence of robotic experience among transplant-track fellows, may leave some graduates poorly positioned for a job market in which patient demand and clinical evidence increasingly favor minimally invasive approaches. Prior research cited in the study indicates that fellowship type independently influences early-career perioperative outcomes, with HPB-specific training associated with superior results, underscoring that these training differences have real clinical consequences.

The study also highlights a structural shift that may widen the disparity. Historically, high-volume HPB fellowships could compress all case requirements into a single year, and most of the high-robotic-volume programs in this dataset were one-year tracks. AHPBA certification requirements are now transitioning to mandate two full years for all fellowships, and current proposals plan to increase both total HPB case requirements and the number of required minimally invasive cases. Doubling the training duration at high-volume centers could give HPB fellows substantially more time to accumulate robotic experience, while many transplant fellowships, the authors note, would already fall below the proposed case volume increases, especially if minimally invasive requirements rise significantly. Canadian programs, which are predominantly two-year and have adopted robotics more slowly due to publicly funded health system structures and reimbursement differences, add further regional variability.

Importantly, the transplant pathway is not uniformly left behind. The authors acknowledge that some transplant programs are outliers with extensive robotic expertise spanning both HPB and transplant operations, and faculty experience, access to dual-console robotic systems, and local practice patterns all shape what an individual fellow encounters. The study also carries methodological limitations that temper its conclusions. The data are fellow-reported and retrospective, and inaccuracies in case logging are well documented, though they diminish with training year and are likely distributed evenly across pathways. Because the data were anonymized, the researchers could not link residency and fellowship experience, meaning each fellow’s cumulative operative exposure across their entire training lifespan is underestimated, nor could they control for the exact months spent on HPB services. The CGSO and TXP fellows studied represent only those programs that chose to offer AHPBA-certified HPB tracks, the most HPB-focused subset of their fields, so the true disparity for the average surgical oncology or transplant graduate is likely even larger than these figures suggest.

Perhaps the deepest question the study raises is whether case counts are the right measure at all. Volume, the authors argue, is an imperfect surrogate for competence: a fellow logged as primary surgeon may have performed very different proportions of an operation at different programs, and current case logs do not capture the degree of attending involvement. As surgical training shifts toward outcomes-based assessment and Entrustable Professional Activities, the traditional case log may need to give way to careful observational evaluation of genuine operative independence. Deliberate practice, coaching, simulation, and post-fellowship mentorship all shape the path to mastery in ways that raw numbers cannot capture. Still, the message for training programs is unambiguous: minimally invasive exposure is distributed unevenly across the pipelines that feed the HPB workforce, graduation volumes fall short of established learning curve thresholds for the most complex robotic operations, and standardized, platform-specific curricula with competency-based assessment are urgently needed. As more residency graduates than ever pursue fellowship and patient demand for robotic liver and pancreas surgery grows, the programs that train tomorrow’s HPB surgeons will need to decide, deliberately and soon, whether they can deliver expertise across transplant, oncology, and HPB domains and across open, laparoscopic, and robotic platforms within a single two-year fellowship.

Subject of Research: Variation in minimally invasive and robotic operative training across hepatopancreatobiliary fellowship pathways

Article Title: Training the next generation of minimally invasive HPB surgeons: are current fellowships crossing the learning curve?

Article References: Caldwell, K. E., Sanford, D. E., & Leigh, N. (2026). Training the next generation of minimally invasive HPB surgeons: are current fellowships crossing the learning curve?. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 186. https://doi.org/10.1007/s44186-026-00602-7

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00602-7

Keywords: HPB surgery, robotic surgery, fellowship training, minimally invasive surgery, surgical education, learning curve, pancreaticoduodenectomy, liver resection, transplant surgery, surgical oncology, AHPBA, case logs