Impact of merging two high-volume centers on patient outcome: 1000 consecutive pancreatoduodenectomies

Background: Pancreatoduodenectomy (PD) has one of the strongest volume-outcome relationships in all of surgery. It is unclear whether this relationship has a plateau for a certain volume. If so, merging two high-volume centers would not lead to further improve patient outcomes. However, data are inappropriate as current studies on volume-outcome relationships are based on a relatively low annual center volumes of 10-50 PDs.

Aim: To compare postoperative outcomes prior and after hospital merger to a very high-volume center.

Methods: Retrospective study assessing the merger of two high-volume university medical centers on outcome of PD (August 2017-March 2025). On May 31, 2021, all pancreatic surgery, multidisciplinary medical, and nursing staff were concentrated on one location and care was harmonized with structural changes in pre-, intra-, and postoperative patient management. Outcomes of 500 consecutive patients undergoing PD pre-merger were compared with 500 consecutive PD post-merger.

Results: During the 7.5-year study period, 1000 patients underwent pancreatoduodenectomy. Pre-merger, the average annual center volume was 42 and 87 PD per center, post-merger this was 133. The use of robot-assisted PD increased post-merger (16% to 36%, p<0.001). Post-merger, the complication-related in-hospital/30-day mortality decreased (2.0% to 0.4%, p=0.020). The failure-to-rescue rate improved (4.9% to 1.1%, p=0.040) post-merger and the rates of major morbidity (Clavien-Dindo≥3) (41% to 35%, p=0.037), postoperative pancreatic fistula grade C (2.4% to 0.8% (p=0.044) and post-pancreatectomy hemorrhage grade B/C (8.0% to 4.6%, p=0.027), including PPH grade C (3.8% vs. 1.6%, p=0.032), decreased.

Conclusion: Surgical outcome after PD improved following the merger of two high-volume centers for pancreatic surgery. These findings may be explained by standardization and proactive multidisciplinary complication management and shed new light on the potential benefits of centralization for pancreatic surgery also for higher volumes of>100 annual caseload.

Publication History

Article published online:
04 September 2025