Surgical decision-making in borderline resectable pancreatic cancer in the era of neoadjuvant therapy: from response assessment to individualized operative strategy.

Background: Neoadjuvant therapy (NAT) has become central to the management of borderline resectable pancreatic ductal adenocarcinoma (BRPC). This surgical narrative review offers a contemporary synthesis of evidence and guidelines, with emphasis on pretreatment staging, post-NAT surgical selection, intraoperative vascular tactics, and postoperative care. Methods: We conducted a structured narrative review of randomized and prospective studies, high-quality observational cohorts, and major international guidelines published through 31 December 2025. A systematic search of PubMed was performed, and key data were synthesized to inform a practical decision-making framework. Results: Although BRPC remains defined largely by vascular anatomy, biological and conditional factors are increasingly incorporated into decision-making. NAT is preferred initially, with resection reserved for carefully selected responders. For post-NAT restaging, contrast-enhanced CT and CA19-9 kinetics are the mainstays, while FDG-PET, DWI-MRI, radiomics, and biomarkers serve as problem-solving adjuncts when findings are equivocal. Surgical exploration is guided by physiologic recovery, absence of metastatic progression, and multidisciplinary consensus. Staging laparoscopy remains useful for detecting occult metastases. Intraoperative vascular resection is margin-driven, not routine: venous resection is standard, arterial resection is selective, and periarterial divestment spares the artery in some cases. Short-term surgical morbidity does not appear to be increased by NAT, yet the absence of uniform protocols for post-reconstruction anticoagulation represents an important area for future investigation. Conclusions: NAT has fundamentally transformed the management of BRPC, establishing a surgical pathway that is dictated by tumor biology and sequentially timed according to treatment response and clinical course. Optimizing outcomes ultimately depends on standardized restaging protocols, judicious selection of patients who truly benefit from resection, and the concentration of complex vascular procedures in high-volume, experienced centers. A practical algorithm is proposed to synthesize these decision points for clinical use.