Impact of Surgical Approach According to PD-ROBOSCORE in Pancreaticoduodenectomy: a Single-center External Validation and Comparative Study

Background Pancreaticoduodenectomy (PD) remains a technically demanding procedure associated with substantial postoperative morbidity. The PD-ROBOSCORE was developed to quantify procedural difficulty using preoperative variables, but external validation and its clinical relevance across different surgical approaches remain limited. This study aimed to validate PD-ROBOSCORE and assess its prognostic performance in predicting major postoperative complications. Methods We conducted a retrospective single-center study including consecutive patients undergoing open or robotic PD between 2020 and 2025. PD-ROBOSCORE was calculated using the original weighted formula and analyzed as a continuous variable, by quartiles, and using the predefined high- difficulty threshold(≥9). The primary endpoint was major postoperative complications (Clavien– Dindo ≥3). Associations were evaluated using logistic regression. Discrimination was assessed using receiver operating characteristic(ROC) analysis. Incremental predictive value was examined by comparing a baseline clinical model with and without PD-ROBOSCORE. Results A total of 381 patients were included;36.5% developed major complications. Higher PD- ROBOSCORE values were independently associated with increased odds of major morbidity(OR 1.12, 95% CI 1.01–1.15; p = 0.02), with a significant trend across quartiles(p=0.011). The score demonstrated good discrimination(AUC 0.727), with similar performance in open and robotic Journal Pre-proof PD(p=0.91). Among high-difficulty cases(n=98), no statistically significant difference in major postoperative complications was observed between robotic and open PD. Addition of PD- ROBOSCORE improved predictive accuracy compared with the clinical model alone(AUC 0.748 vs 0.673; p=0.003). Conclusions PD-ROBOSCORE is an effective predictor of major postoperative morbidity after PD and provides incremental prognostic value beyond patient-related factors. It may support preoperative risk stratification and surgical decision-making, particularly in technically complex cases.