Surgeons need to balance level 1 evidence and experiential insight in mitigating pancreatic fistulas after pancreatoduodenectomy.

• Analysis of 37 randomized controlled trials reveals low patient inclusion rates (39.6%) and significant discord in findings for 6 of 7 mitigation techniques.
• Meta-analyses provided more consistent conclusions than individual trials, yet rates of clinically relevant fistulas differed notably between trial participants and experiential data cohorts.

Understanding these discrepancies can help tailor strategies for risk stratification, improving patient outcomes and surgical decision-making.

• Experiences with stents, drains, and early drain removal align with level 1 data, while approaches like pancreatogastrostomy require further scrutiny.