Pancreatic ductal adenocarcinoma and pancreatic surgery in the 21st century: triumphs, turning points, and unresolved challenges.

Outcomes in pancreatic cancer surgery have been constrained by high operative risks and by the unfavorable biological behavior of most pancreatic neoplasms. This narrative review summarizes the major developments that have reshaped the surgical management of pancreatic ductal adenocarcinoma over the past twenty-five years and highlights their interaction with advances in oncologic therapies. Although no single innovation has been decisively transformative, the overall quality of care has improved substantially. The introduction of objective scoring systems has standardized the classification of postoperative complications and enhanced the accuracy of perioperative risk assessment. Combined with technical refinements and improved perioperative management, these tools have contributed to a measurable reduction in postoperative mortality. In parallel, progress in oncologic therapies has increased five-year survival from less than 5% to approximately 13%. From a surgical standpoint, important progress includes the adoption of minimally invasive procedures, recently advanced by robotics, and the incorporation of venous and arterial resections within prognosis-based resectability strategies. Nonetheless, the full potential of these approaches has yet to be defined, as most data originate from centers still completing the required learning curves. Optimal management of pancreatic tumors requires care in dedicated pancreas units within broader networks that centralize patients to hospitals meeting the logistical, technological, cultural, and professional standards needed to deliver the full range of treatments, from palliation to the most advanced oncologic interventions. For borderline-resectable and locally advanced tumors, centralization should consider not only institutional volume but also the specific technical expertise required.