Volume-Outcome Relationship in Pancreatic Surgery

In pancreatic surgery the correlation between hospital volume and postoperative outcomes has been widely demonstrated. Hospital volume is a recognized independent determinant for in-hospital mortality, mainly due to a different effectiveness in the management of major postoperative complications. European countries and the United States have been pursuing centralization policies based on minimal annual hospital and surgeon volumes, in order to guarantee the lowest morbidity and mortality rates. In Italy, two models have been proposed as an alternative to centralization and both are founded on the decentralization of expertise to low-volume centers. The most recent evidence drawn from the Italian pancreatic surgery scene have confirmed the volume-outcome relationship and have shown the worrying features of surgery in low-volume hospitals: more non-resective surgery, higher mortality, and excessive costs. Also, a geographical gradient in mortality rates has been demonstrated in Italy: the highest mortality is observed in southern regions and the lowest in northern regions, but patient mobility reduces this difference. A centralization policy, based either on individual hospital outcomes or on a volume criterion, is certainly needed in our country and should pass through the regional accreditation of high-quality surgery hospitals and the homogeneous distribution of referral centers throughout the national territory.