Pancreatic cancer is among the most lethal cancers, with a five-year survival rate of only around 12%. Pancreaticoduodenectomy (PD) is the standard treatment, mainly for tumors in the head of the pancreas, involving the removal of the pancreatic head, the duodenum, the gallbladder, part of the bile ducts, and occasionally part of the stomach. Following this resection, surgeons reconstruct the digestive tract by creating new connections between the bile duct, stomach, pancreas, and remaining small intestine. While PD can effectively treat pancreatic cancer, it also carries significant risks. One of the most serious complications, occurring in 9-18% of cases, is the formation of a pancreatic fistula. A fistula is an abnormal connection between organs or between an organ and the skin, allowing fluids to leak where they shouldn’t. In pancreatic fistulas, digestive fluids leak from the pancreas, potentially harming nearby organs. Managing these fistulas can be complex, particularly in severe cases classified as grade C pancreatic fistulas. Grade C fistulas often require intensive treatments, such as additional surgeries or procedures, as they cannot be managed with conservative methods alone. Despite the severity of grade C pancreatic fistulas, there is no consensus on the optimal treatment approach. This study aimed to review current evidence on managing grade C pancreatic fistulas following PD surgery, hoping to clarify the most effective treatment options. One common approach is to remove the entire pancreas, known as a total pancreatectomy. However, this procedure inevitably leads to diabetes, specifically a difficult-to-manage form called brittle diabetes. Brittle diabetes causes large fluctuations in blood sugar, increasing the risk of serious complications such as hypoglycemia, and requires lifelong insulin therapy. This not only affects patients' quality of life but also adds to healthcare costs. In this study, we compared various treatment options, including non-surgical and surgical approaches, as well as different surgical techniques. We hope these findings can guide physicians and patients in selecting the most effective treatment strategy for managing severe pancreatic fistulas after PD surgery.