New horizons in the surgical treatment of pancreatic ductal adenocarcinoma: from biological selection to surgical strategy
Lorenzo Epis, Carlo Giovanni Ferrari, Ettore Colangelo, Maria Lucia Izzo, Nicola Cinardi, Tiziana Viora, Alessandro Giardino, Leonardo Vincenti, Michele Mazzola, Christian Cotsoglou, Carlo Molino, Raffaele Romito, Tommaso Nelli, Sergio Li Petri, Lorenzo Livraghi, Angela Maffongelli, Lorenzo Maganuco, Vincenzo Scuderi, Riccardo Memeo, Cataldo De Palma, Michele Paterno, Nicola Cillara, Andrea Sagnotta, Matteo Santoliquido, Lorenzo Pandolfini, Francesco Fleres, Federica Frongia, Luciana Pisano, Veronica Bandera, Alberto Molteni,Background:
To synthesize current evidence and the structured expert perspectives presented during a dedicated session on pancreatic ductal adenocarcinoma, focusing on the transition from anatomical to biological definitions of resectability, neoadjuvant therapy, minimally invasive and artery-first surgery, postoperative pancreatic fistula, and perioperative optimization.
Methods:
This narrative review was developed according to the standardized artificial intelligence-assisted, clinician-supervised methodology described by Molteni et al. The review is based on the complete audiovisual recording and original presentations of the Pancreatic Surgery session held during the 44th National Congress of the Italian Association of Hospital Surgeons (ACOI), Palermo, Italy (24–27 May 2026), and integrates the expert discussion with contemporary peer-reviewed evidence from randomized controlled trials, meta-analyses, and observational studies. No patient data were collected.
Results:
Biological characteristics emerged as the principal determinant of outcome, while margin-negative (R0) resection remained the main modifiable surgical objective. Resectability is evolving from a purely anatomical concept toward an integrated anatomical, biological, and physiological assessment. Evidence on neoadjuvant therapy for resectable disease remains heterogeneous but supports its role as a tool for biological selection. Minimally invasive distal pancreatectomy is well established, whereas minimally invasive pancreatoduodenectomy requires high procedural volumes and structured training. Postoperative pancreatic fistula is managed through risk stratification and early diagnosis rather than a single superior preventive strategy. Prehabilitation and enhanced recovery reduce postoperative morbidity without demonstrated mortality benefit.
Conclusions:
Contemporary management of pancreatic ductal adenocarcinoma integrates biological selection, individualized surgical decision-making, technical standardization in high-volume centers, and an explicit distinction between beneficial and futile surgery.