Risk prediction platform for pancreatic fistula after pancreatoduodenectomy using artificial intelligence

Abstract

Background: Despite advancements in operative technique and improvements in postoperative managements, postoperative pancreatic fistula (POPF) is a life-threatening complication following pancreatoduodenectomy (PD). There are some reports to predict POPF preoperatively or intraoperatively, but the accuracy of those is questionable. Artificial intelligence (AI) technology is being actively used in the medical field, but few studies have reported applying it to outcomes after PD.

Aim: To develop a risk prediction platform for POPF using an AI model.

Methods: Medical records were reviewed from 1769 patients at Samsung Medical Center who underwent PD from 2007 to 2016. A total of 38 variables were inserted into AI-driven algorithms. The algorithms tested to make the risk prediction platform were random forest (RF) and a neural network (NN) with or without recursive feature elimination (RFE). The median imputation method was used for missing values. The area under the curve (AUC) was calculated to examine the discriminative power of algorithm for POPF prediction.

Results: The number of POPFs was 221 (12.5%) according to the International Study Group of Pancreatic Fistula definition 2016. After median imputation, AUCs using 38 variables were 0.68 ± 0.02 with RF and 0.71 ± 0.02 with NN. The maximal AUC using NN with RFE was 0.74. Sixteen risk factors for POPF were identified by AI algorithm: Pancreatic duct diameter, body mass index, preoperative serum albumin, lipase level, amount of intraoperative fluid infusion, age, platelet count, extrapancreatic location of tumor, combined venous resection, co-existing pancreatitis, neoadjuvant radiotherapy, American Society of Anesthesiologists' score, sex, soft texture of the pancreas, underlying heart disease, and preoperative endoscopic biliary decompression. We developed a web-based POPF prediction platform, and this application is freely available at http://popfrisk.smchbp.org.

Conclusion: This study is the first to predict POPF with multiple risk factors using AI. This platform is reliable (AUC 0.74), so it could be used to select patients who need especially intense therapy and to preoperatively establish an effective treatment strategy.

Keywords: Neural networks; Pancreatoduodenectomy; Postoperative pancreatic fistula; Recursive feature elimination.

Figure 1

Performance of the neural network models optimized within each recursive feature elimination step. 1: Pancreatic duct diameter; 2: Body mass index; 3: Serum albumin; 4: Amount of intraoperative fluid infusion; 5: Age; 6: Platelet count; 7: Extrapancreatic location of tumor; 8: Combined venous resection; 9: Co-existing pancreatitis; 10: Serum lipase; 11: Neoadjuvant radiotherapy; 12: ASA score; 13: Sex; 14: Soft texture of pancreas; 15: Underlying heart disease; 16: Preoperative endoscopic biliary decompression; 17: Hemoglobin; 18: Serum total bilirubin; 19: Operative time; 20: Intraoperative transfusion; 21: Neoadjuvant chemotherapy; 22: Anastomotic methods (1); 23: Serum amylase; 24: Anastomotic methods (2-1); 25: Pancreatic duct stent (1); 26: White blood cell count; 27: Type of surgery (1); 28: Serum carbohydrate antigen 19-9; 29: Serum C- reactive protein; 30 Estimated blood loss; 31: Combined vascular resection; 32: Pancreatic duct stent (2); 33: Preoperative percutaneous biliary drainage; 34: Underlying cerebrovascular disease; 35: Combined organ resection; 36: Type of surgery (2); 37: Type of surgery (3); 38: Anastomotic methods (2-2); 39: Underlying liver disease; 40: Underlying chronic kidney disease; 41: Underlying pulmonary disease; 42: Underlying cerebrovascular disease; 43: Diabetes mellitus; 44: Preoperative endoscopic pancreatic drainage; ASA: American Society of Anesthesiologists; AUC: Area under the curve.

Figure 2

Illustration of artificial intelligence algorithm for 16 risk factors affecting postoperative pancreatic fistula. PV-SMV: Portal vein-superior mesenteric vein; ASA: American Society of Anesthesiologists; ERBD: Endoscopic retrograde biliary drainage; ENBD: Endoscopic nasobiliary drainage; POPF: Postoperative pancreatic fistula.