Centralizing a national pancreatoduodenectomy service: striking the right balance

Background: Centralization of pancreatic surgery is currently called for owing to superior outcomes in higher-volume centres. Conversely, organizational and patient concerns speak for a moderation in centralization. Consensus on the optimal balance has not yet been reached. This observational study presents a volume-outcome analysis of a complete national cohort in a health system with long-standing centralization. Methods: Data for all pancreatoduodenectomies in Norway in 2015 and 2016 were identified through a national quality registry and completed through electronic patient journals. Hospitals were dichotomized (high-volume (40 or more procedures/year) or medium-low-volume). Results: Some 394 procedures were performed (201 in high-volume and 193 in medium-low-volume units). Major postoperative complications occurred in 125 patients (31.7 per cent). A clinically relevant postoperative pancreatic fistula occurred in 66 patients (16.8 per cent). Some 17 patients (4.3 per cent) died within 90 days, and the failure-to-rescue rate was 13.6 per cent (17 of 125 patients). In multivariable comparison with the high-volume centre, medium-low-volume units had similar overall complication rates, lower 90-day mortality (odds ratio 0.24, 95 per cent c.i. 0.07 to 0.82) and no tendency for a higher failure-to-rescue rate. Conclusion: Centralization beyond medium volume will probably not improve on 90-day mortality or failure-to-rescue rates after pancreatoduodenectomy.