Perri G, Marchegiani G, Partelli S, et al. - As intraoperative parameters are used in existing postoperative pancreatic fistula risk scores, hence these scores have limited value in the preoperative setting. Researchers herein constructed a preoperative predictive model to stratify the risk of developing postoperative pancreatic fistula before pancreatoduodenectomy and validated it externally. In the Verona University Hospital training cohort, development of a regression risk-tree model was done using preoperative variables for the stratification of preoperative postoperative pancreatic fistula risk. Then the model was examined prospectively in a validation cohort of patients who underwent pancreatoduodenectomy at San Raffaele Hospital of Milan. During the study period, pancreatoduodenectomy was performed on 566 (training cohort) and 456 (validation cohort) patients. The multivariable analysis led to identification of following factors to be independently linked with postoperative pancreatic fistula: body mass index, radiographic main pancreatic duct diameter and American Society of Anesthesiologists score ≥ 3. Findings suggest that quick and accurate assessment of the risk of postoperative pancreatic fistula can be done in the preoperative setting based on the body mass index and main pancreatic duct diameter at radiology. They indicate potential value of preoperative risk stratification for clinical decision-making, improving patient counseling and establishing personalized preoperative protocols.