Impact of Merging two high-volume Centers on Patient Outcome

Aim: To assess the impact of a merger of two high-volume centers for pancreatic surgery. Background: Pancreatoduodenectomy (PD) has one of the strongest volume-outcome relationships in surgery. Allegedly, this relationship plateaus beyond annual center volumes of 40-50 PD. If so, merging two high-volume centers would not lead to improvement in patient outcome but data are lacking. Methods: Retrospective study assessing the merger of two high-volume university medical centers on outcome of PD using data from the prospective and mandatory Dutch Pancreatic Cancer Audit (DPCA) (August 2017-March 2025). On May 31, 2021, the multidisciplinary pancreatic surgery services of both centers were concentrated on one location including implementing several surgical and structural changes in patient and complication management. Outcomes of 500 consecutive patients undergoing PD pre-merger were compared with 500 consecutive patients post-merger. Results: Overall, 1000 patients undergoing PD were included. Pre-merger, the average annual center volumes were 42 and 87 PD, 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), as did the rates of failure-to-rescue (4.9% to 1.1%, P =0.040), 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). Outcomes improved for both centers. Conclusion: The merger of two high-volume centers for pancreatic surgery was associated with improved major morbidity, failure-to-rescue, and complication-related mortality following PD. This improvement, attributed to both improved patient management and increased surgical volume, highlights the potential for improving patient outcome.