External Validation of the Auditing Fistula Risk Score for Pancreatoduodenectomy

BACKGROUND: Postoperative pancreatic fistula (POPF) complicates 10%-25% of pancreatoduodenectomies (PDs). This study sought to validate the recent Auditing Fistula Risk Score (Auditing-FRS). METHODS: PDs recorded in the 2015-2023 National Surgical Quality Improvement Program (NSQIP) were analyzed. Multivariable logistic regression confirmed independent predictors. Discrimination was quantified using the area under the receiver operating characteristic curve (AUC). Calibration was assessed using the Brier score, and decision-curve analysis (DCA) evaluated clinical utility across overall, open (OPD), laparoscopic (LPD), and robotic (RPD) subgroups. RESULTS: Among 25 250 PDs, POPF occurred in 12.6% of cases. All Auditing-FRS predictors remained independently associated with POPF. The AUC was 0.694 (95% confidence interval [CI] 0.684-0.704) for the overall cohort, with comparable performance across operative subgroups: OPD 0.693 (95% CI 0.683-0.703), LPD 0.708 (95% CI 0.672-0.745), and RPD 0.701 (95% CI 0.657-0.744). Predicted and observed POPF probabilities were closely aligned. DCA demonstrated that within the clinically relevant threshold range of 5%-30%, the Auditing-FRS consistently offered greater net benefit than treating all or no patients. CONCLUSION: The Auditing-FRS demonstrates acceptable discrimination and good calibration in a large NSQIP cohort across open, laparoscopic, and robotic approaches, supporting its use for institutional benchmarking and perioperative risk stratification.