The image-based preoperative fistula risk score (preFRS) predicts postoperative pancreatic fistula in patients undergoing pancreatic head resection

Abstract

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common severe surgical complication after pancreatic surgery. Current risk stratification systems mostly rely on intraoperatively assessed factors like manually determined gland texture or blood loss. We developed a preoperatively available image-based risk score predicting CR-POPF as a complication of pancreatic head resection. Frequency of CR-POPF and occurrence of salvage completion pancreatectomy during the hospital stay were associated with an intraoperative surgical (sFRS) and image-based preoperative CT-based (rFRS) fistula risk score, both considering pancreatic gland texture, pancreatic duct diameter and pathology, in 195 patients undergoing pancreatic head resection. Based on its association with fistula-related outcome, radiologically estimated pancreatic remnant volume was included in a preoperative (preFRS) score for POPF risk stratification. Intraoperatively assessed pancreatic duct diameter (p < 0.001), gland texture (p < 0.001) and high-risk pathology (p < 0.001) as well as radiographically determined pancreatic duct diameter (p < 0.001), gland texture (p < 0.001), high-risk pathology (p = 0.001), and estimated pancreatic remnant volume (p < 0.001) correlated with the risk of CR-POPF development. PreFRS predicted the risk of CR-POPF development (AUC = 0.83) and correlated with the risk of rescue completion pancreatectomy. In summary, preFRS facilitates preoperative POPF risk stratification in patients undergoing pancreatic head resection, enabling individualized therapeutic approaches and optimized perioperative management.

Prediction of clinically relevant postoperative pancreatic fistula using radiomic features and preoperative data

“…The patients with below average values of F 4 IVH had an increased risk of CR-POPF as predicted by the radiomic signature model (Figure 2). Since this feature showed a direct association with the intraoperative pancreatic duct width with a Spearman correlation co-efficient of ρ = 0.53 (Figure 5), the results are in agreement with recent studies 16,17 , in which a narrow pancreatic duct was associated with higher risk of CR-POPF. A narrow pancreatic duct is also one of the most relevant intraoperatively determined CR-POPF risk factors 6,13 .…”

“…From the feature expression map shown in Figure 2, it is evident that the model tends to predict a higher risk of CR-POPF for patients with above average values of this texture feature. The radiomic texture feature F3 T was also found to be associated with soft intraoperative pancreatic texture (Figure 5), which was found to be an indication of CR-POPF occurrence 6,16 . The assessment of pancreatic texture is one of the most commonly applied intraoperative methods of assessing CR-POPF risk.…”

“…Figures 4 and 5 show the association between the radiomic signature features and the established risk factors for CR-POPF such as pancreatic texture, estimated PRV and pancreatic duct width 16 . The data for these risk factors was available for 70 out of the 148 patients analyzed in this study.…”

“…The features with significant association with the CR-POPF outcome ( p < 0.05) were standardised, and heatmaps of the resulting standardised features were visualised for the entire patient cohort in order to qualitatively assess the trends and correlations with the outcome. Additionally, the features included in the radiomic signature were compared with established risk factors 16 such as intraoperative pancreatic texture and pancreatic duct width, and preoperatively estimated pancreatic remnant volume (PRV). The standardised values of these established risk factors were plotted against the corresponding standardised values of the radiomic features.…”

“…However, an early and accurate risk estimate based on the vast amount of available preoperative data has the potential to play a key role in pre-surgical decision-making, especially in case of patients with terminal illness like the cancer patients, where postoperative complications could delay or impede neoadjuvant therapy. For instance, small pancreatic duct size and large pancreatic remnant volume (PRV), estimated from preoperative computed tomography (CT) images, was found to be significantly associated with the risk of CR-POPF after pancreatic head resection [14][15][16][17] . The preoperative risk estimate could also complement the intraoperative and postoperative findings for better patient state monitoring.…”