{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T10:25:31Z","timestamp":1792664731175,"version":"4.5.0"},"reference-count":112,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,2,14]],"date-time":"2026-02-14T00:00:00Z","timestamp":1771027200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Pancreatic surgery is a technically demanding field associated with frequent morbidity, with pancreatic fistula representing the dominant driver of major complications in pancreaticoduodenectomy (PD). Although refinements in operative technique, perioperative management, and institutional systems have contributed to incremental improvements, the overall incidence of clinically relevant complications has remained largely unchanged over recent decades. This narrative review provides a comprehensive overview of current strategies aimed at reducing morbidity and mortality after pancreaticoduodenectomy, focusing on modifiable technical, pharmacological, nutritional, and systems-based interventions, whilst acknowledging the underlying biological determinants that remain difficult to alter. This review synthesises contemporary evidence on fistula risk modelling, anastomotic reconstruction, and adjunctive operative techniques. The role of pharmacological interventions is examined alongside an evaluation of perioperative nutritional optimisation and enhanced recovery frameworks. Systems-based strategies such as centralisation, failure-to-rescue performance, protocolised pathways, and algorithm-driven postoperative surveillance are highlighted as emerging areas with substantial potential to impact survival independently of complication rates. Finally, this review explores future directions, including radiomics-based risk stratification, intraoperative imaging, and tailored postoperative care. Together, these domains provide a platform for reducing complication severity, standardising postoperative care, and ultimately improving patient outcomes. By integrating these perspectives, this review aims to present a comprehensive and in-depth narrative of how to reduce complications in pancreas surgery. Overall, this narrative review proposes that meaningful improvements in outcomes after PD likely do not arise from the elimination of complications altogether, but rather from improved prediction, prevention where possible, and critically, more effective systems of care that reduce the severity and consequences of complications when they occur.<\/jats:p>","DOI":"10.3390\/cancers18040630","type":"journal-article","created":{"date-parts":[[2026,2,16]],"date-time":"2026-02-16T14:09:54Z","timestamp":1771250994000},"page":"630","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Reducing Complications in Pancreaticoduodenectomy"],"prefix":"10.3390","volume":"18","author":[{"given":"Josh B.","family":"Karpes","sequence":"first","affiliation":[{"name":"Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Camperdown, Sydney 2050, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0453-3168","authenticated-orcid":false,"given":"Ken","family":"Liu","sequence":"additional","affiliation":[{"name":"Australian National LT Unit, Royal Prince Alfred Hospital, Sydney 2050, Australia"},{"name":"Sydney Medical School, University of Sydney, Sydney 2006, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael D.","family":"Crawford","sequence":"additional","affiliation":[{"name":"Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Camperdown, Sydney 2050, Australia"},{"name":"Australian National LT Unit, Royal Prince Alfred Hospital, Sydney 2050, Australia"},{"name":"RPA Institute of Academic Surgery, University of Sydney, Sydney 2006, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlo","family":"Pulitano","sequence":"additional","affiliation":[{"name":"Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Camperdown, Sydney 2050, Australia"},{"name":"Australian National LT Unit, Royal Prince Alfred Hospital, Sydney 2050, Australia"},{"name":"RPA Institute of Academic Surgery, University of Sydney, Sydney 2006, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charbel","family":"Sandroussi","sequence":"additional","affiliation":[{"name":"Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Camperdown, Sydney 2050, Australia"},{"name":"Australian National LT Unit, Royal Prince Alfred Hospital, Sydney 2050, Australia"},{"name":"RPA Institute of Academic Surgery, University of Sydney, Sydney 2006, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1123-0122","authenticated-orcid":false,"given":"Jerome M.","family":"Laurence","sequence":"additional","affiliation":[{"name":"Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Camperdown, Sydney 2050, Australia"},{"name":"Australian National LT Unit, Royal Prince Alfred Hospital, Sydney 2050, Australia"},{"name":"RPA Institute of Academic Surgery, University of Sydney, Sydney 2006, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1016\/j.surg.2005.05.001","article-title":"Postoperative pancreatic fistula: An international study group (ISGPF) definition","volume":"138","author":"Bassi","year":"2005","journal-title":"Surgery"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"584","DOI":"10.1016\/j.surg.2016.11.014","article-title":"The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After","volume":"161","author":"Bassi","year":"2017","journal-title":"Surgery"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1016\/S2468-1253(16)30004-8","article-title":"Global incidence and mortality of pancreatic diseases: A systematic review, meta-analysis, and meta-regression of population-based cohort studies","volume":"1","author":"Xiao","year":"2016","journal-title":"Lancet Gastroenterol. 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