Identifying effective strategies for preventing postoperative pancreatic fistula (POPF) can significantly impact patient outcomes after pancreatoduodenectomy (PD).

• Overall POPF rate was 15.1%; drains alone showed no association with POPF.
• For moderate fistula risk score patients, drains alone reduced POPF from 19.8% to 13.1%.
• High-risk patients benefited most from a drain combined with a stent, lowering POPF from 38.5% to 23.7%.

Emphasizing these optimal strategies could cut fistula rates by a third, and up to half when early drain removal is applied.