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

Patients with pancreatic ductal adenocarcinoma (PDAC) proceeding to pancreaticoduodenectomy rarely have a single nutritional problem. Poor intake may coexist with pancreatic exocrine insufficiency, loss of muscle function, systemic inflammation, and unstable glucose control. Screening tools identify vulnerability, but they do not show which of these processes is most important at a particular point in treatment. This Perspective sets out a domain-guided approach in which screening is followed by an explicit treatment hypothesis. Four overlapping domains are considered: muscle loss and functional decline; pancreatic exocrine insufficiency and impaired digestion; inflammatory and catabolic burden; and glycemic instability with pancreatic endocrine insufficiency. The domains are not new diagnoses and do not replace the Nutrition Care Process. They are a practical way to connect a clinically important finding with a defined action, a responsible clinician, a response measure, an escalation rule, and a reassessment date. Intake and symptom burden are treated as cross-cutting variables because they influence every domain. The framework is intended for use during neoadjuvant treatment, the preoperative interval, hospitalization, and early recovery. Its value will depend on whether it improves function, symptom control, protein-energy adequacy, glycemic stability, postoperative recovery, and delivery of planned oncologic treatment.