Background <p>To evaluate the impact of pancreatic duct stent outcomes on the prognosis of postoperative pancreatic fistula in patients with high-risk anastomoses.</p> Methods <p>Randomized controlled trials were identified through comprehensive searches in Cochrane Library, Web of Science, Embase, and PubMed databases. Cochrane Collaboration’s tool RoB2 was used to evaluate study quality. The presence of non-dilated main pancreatic duct and soft gland texture were used to identify high risk anastomoses. The primary outcome measured was clinically relevant postoperative pancreatic fistula rate. The heterogeneity and sensitivity analyses were performed.</p> Results <p>Six studies (<i>n</i> = 476) were included. The pooled data showed no significant difference in the clinically relevant postoperative pancreatic fistula rate between stented and nonstented groups for at least one high-risk factor out of two factors selected (<i>p</i> = 0.234). Patients with non-dilated main pancreatic duct who received stent placement had a lower clinically relevant postoperative pancreatic fistula rate (RR = 0.582, 95%CI = 0.383–0.883, <i>p</i> = 0.011). In contrast, patients with soft pancreatic texture showed no significant difference between two groups (<i>p</i> = 0.879). After removing the study identified by sensitivity analysis as the origin of heterogeneity from general cohorts, the stented group had a lower clinically relevant postoperative pancreatic fistula rate (RR = 0.608, 95%CI = 0.413–0.895, <i>p</i> = 0.012).</p> Conclusions <p>There is a lack of robust evidence to support pancreatic duct stent placement for high-risk anastomoses. Nevertheless, stent implantation may be beneficial for patients with non-dilated pancreatic duct or external stent drainage.</p> Trial registration <p>The protocol was registered in advance with PROSPERO (CRD42023471943).</p>