# Multi-Modal Machine Learning for Evaluating the Predictive Value of Pelvimetric Measurements (Pelvimetry) for Anastomotic Leakage After Restorative Low Anterior Resection

## TL;DR

This study explores how MRI-based pelvic measurements and machine learning can help predict the risk of anastomotic leakage after rectal cancer surgery.

## Contribution

The study introduces a multi-modal approach combining pelvimetry and clinical data with machine learning to predict anastomotic leakage risk.

## Key findings

- Pelvic inlet width and interspinous distance were identified as independent risk factors for anastomotic leakage.
- Machine learning models incorporating pelvimetry showed moderate predictive performance with a mean ROC-AUC of 0.70.
- Including pelvimetry in models improved predictive performance, though the improvement was not statistically significant.

## Abstract

Anastomotic leakage is a serious complication following rectal cancer surgery, which can lead to poor outcomes and prolonged recovery. The accurate preoperative identification of patients at higher risk is challenging. In this study, we analyzed pelvis measurements obtained from MRI scans, known as pelvimetry, to assess whether these dimensions could help predict the likelihood of anastomotic leakage. We also used machine learning models to combine pelvimetry with clinical data and evaluate their predictive performance. Our results identified key pelvic dimensions, such as the pelvic inlet width and interspinous distance, as potential risk factors for anastomotic leakage. While the predictive models showed moderate performance, these findings suggest that incorporating pelvimetric measurements into clinical risk assessments may help surgeons improve preoperative planning and patient safety in rectal cancer surgery.

Background/Objectives: Anastomotic leakage (AL) remains a major complication after restorative rectal cancer surgery, with accurate preoperative risk stratification posing a significant challenge. Pelvic measurements derived from magnetic resonance imaging (MRI) have been proposed as potential predictors of AL, but their clinical utility remains uncertain. Methods: This retrospective, multicenter cohort study analyzed rectal cancer patients undergoing restorative surgery between 2013 and 2021. Pelvic dimensions were assessed using MRI-based pelvimetry. Univariate and multivariate regression analyses identified independent risk factors for AL. Subsequently, machine Learning (ML) models—logistic regression, random forest classifier, and XGBoost—were developed to predict AL using preoperative clinical data alone and in combination with pelvimetry. Model performance was evaluated using F1 scores, with the area under the receiver operating characteristic (ROC-AUC) and precision–recall curves (AUC-PR) as primary metrics. Results: Among 487 patients, the overall AL rate was 14%. Multivariate regression analysis identified distance to the anorectal junction, pelvic inlet width, and interspinous distance as independent risk factors for AL (p < 0.05). The logistic regression model incorporating pelvimetry achieved the highest predictive performance, with a mean ROC-AUC of 0.70 ± 0.09 and AUC-PR of 0.32 ± 0.10. Although predictive models that included pelvic measurements demonstrated higher ROC-AUCs compared to those without pelvimetry, the improvement was not statistically significant. Conclusions: Pelvic dimensions, specifically pelvic inlet and interspinous distance, were independently associated with an increased risk of AL. While ML models incorporating pelvimetry showed only moderate predictive performance, these measurements should be considered in developing clinical prediction tools for AL to enhance preoperative risk stratification.