Breakdown analysis of the cost development of pancreatic surgery after centralization

Abstract

Background

Centralization of pancreatic surgery has been shown to improve short-term outcomes and reduce postoperative mortality. Whether these clinical gains translate into lower costs is less clear, and evidence on the relationship between volume and cost remains inconsistent. In this study, we performed an itemized cost analysis of the pancreatic surgery process over the first decade following centralization. The primary objectives were to evaluate whether surgical costs have changed over time and to identify the main drivers of post-centralization costs.

Methods

The retrospective single-centre study included 403 consecutive patients who underwent pancreatic resections at Oulu University Hospital between 2013–2021. Clinicopathological variables were collected from patient records. Direct hospital costs were calculated using inflation-adjusted tariffs for various subcategories: operation room (OR) costs, ward days, intensive care unit (ICU) stay, radiological imaging, laboratory tests, endoscopies and interventional radiology procedures.

Results

The median total cost per pancreatectomy patient was €23,521. The largest cost components were OR expenses (median €10,659) and the postoperative ward care (median €6,677). While complications (Clavien-Dindo III–V) significantly correlated with higher expenses (P<0.001), total costs per patient rose by €11,190 during the study period despite a stable complication rate. The most significant increases occurred in OR costs (€8,941 to €15,136) and ward costs (€4,480 to €7,450). Median hospital costs for patients who underwent vascular reconstructions were higher than for patients with no vascular reconstruction (€27,683 vs. €22,401, P<0.001), while complication rates did not differ (P=0.051). In quantile regression analysis, distal pancreatic resection was associated with lower costs than pancreatoduodenectomy in patients with no or minor complications (adjusted P<0.001). Associations between cost and vascular reconstruction among patients with major complications did not remain significant after correction for multiple testing.

Conclusions

Costs of pancreatic surgery rose steadily during the first decade following centralization, despite a stable complication rate. In quantile regression analysis, only procedure type remained a significant cost driver after correction for multiple testing. OR costs and postoperative ward care accounted for most of the rising expenses.

Highlight box.

Key findings

• Inflation-adjusted total costs of pancreatic surgery rose about €11,190 per patient in study period (2013–2021) at a single center, despite a stable postoperative complication rate. The largest cost increase was in operation room (OR) expenses (€8,941 to €15,136) and postoperative ward care (€4,480 to €7,450). Among patients with no or minor complications, procedure type was the main cost driver, with distal pancreatic resection associated with lower costs than pancreatoduodenectomy.

What is known and what is new?

• Complications are established cost drivers in pancreatic surgery, roughly doubling total care cost. Whether centralization reduces costs is unclear. Evidence on volume and cost is inconsistent, and high-volume referral has not lowered costs.

• This study adds a detailed, itemized sub-cost breakdown of the first decade after centralization, showing that rising OR and ward care costs are the contributions to the overall increase, with steady complication rates. In quantile regression analysis, procedure type was the only cost driver remaining significant after correction for multiple testing, with distal pancreatectomy associated with lower costs than pancreatoduodenectomy among patients with no or minor complications.

What is the implication, and what should change now?

• Cost rose after centralization even though the complication rate remained stable, and the increase was concentrated in OR and ward rather than in other components. Because procedure type was the only cost driver to persist after correction for multiple testing, cost-reduction efforts should target OR utilization and ward-level care pathways rather than undifferentiated cuts.

Introduction

Background

Pancreatic surgery is associated with a high incidence of postoperative complications and 1–3% postoperative mortality (1). Centralization of pancreatic surgery has been shown to improve short-term results of pancreatic surgery by reducing complications, and particularly the failure to rescue (FTR) rate (2). Accordingly, minimum annual volume thresholds have been proposed to define adequate institutional experience for pancreatoduodenectomy (3).

Complications are the best-established drivers of cost in any type of surgery, and their effect in over doubling the expenses also in pancreatic surgery has been shown in several studies (4-6). Delayed gastric emptying, clinically relevant postoperative pancreatic fistula, respiratory failure, and deep vein thrombosis /pulmonary embolism have been recognized as complications promoting most expenses (7).

Whether the clinical gains of centralization translate into lower costs is, however, considerably less clear. A systematic review of economic impact of centralizing cancer services concluded that although increasing surgeon volume is often associated with cost reductions, the evidence for hospital-volume effects on cost is inconsistent and the overall economic impact of centralization remains unclear (8). Consistent with this uncertainty, national data show wide interhospital variation in the cost of pancreatoduodenectomy (9), and referral to high-volume centres has not been found to reduce overall costs, with no demonstrable relationship between surgical volume and cost (10).

Rationale and knowledge gap

During the last decade, in addition to centralization, other modifications in health care processes with direct cost effects have emerged. For instance, wider adoption of mini-invasive surgery, higher complexity of operations with vascular reconstructions, implementation of perioperative care pathways and advanced complication management all likely have an impact on total surgical costs. Several previous reports exist with comparisons of costs and other outcomes between high-volume hospital (HVH) and low-volume hospital (LVH), high-volume definitions being arbitrary, and cost analyses building on register-based crude values (11). Evolution of detailed expenses as a function of increasing hospital volume over time has not been investigated before.

Objective

Previously, we have shown that the rate of postoperative complications remained essentially constant after centralization of pancreatic surgery (2011–2012) to our tertiary care centre, Oulu University Hospital, but the FTR rate decreased significantly (12) . The present study uses a partially overlapping patient population with the previous report but is restricted in this work to patients treated after centralization (2013–2021). While our earlier study addressed clinical short- and long-term outcomes, the current study reports how itemized hospital costs evolved during the first decade following centralization and aims to identify the clinical and operative factors driving these changes. Secondarily, we aimed to recognize the specific drivers of costs in patients with no or minor complications. This approach was chosen to address the dilemma of rising costs and stable or decreasing complication rates. We present this article in accordance with the STROBE reporting checklist (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-0637/rc).

Methods

Data collection

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the University of Oulu (No. EETTMK 81/2008). The National Authority for Medicolegal Affairs (VALVIRA) has approved the use of data and samples and thus waived the need for informed consent. Consecutive pancreatectomy patients were collected from the Oulu University Hospital operational planning program from 2013–2021. Clinical patient data were obtained from the medical records at Oulu University Hospital, and pathology reports from the Department of Pathology archives. Pricing of services was acquired from the Oulu University Hospital tariffs ledger for hospital services in 2013–2021 to compare actual cost differences, unaffected by billing variations. Pricing of annual laboratory services was acquired from the local, public-owned laboratory testing provider, Nordlab. All patients who underwent pancreatic resection at Oulu University Hospital between 2013 and 2021 and for whom complete data were available were included in the study. No patients were excluded. Not every patient underwent all individual investigations included in the cost analysis, which reflects normal variation in clinical care rather than missing data, and affected 352/403 patients (87.3%). A separate issue concerned the itemized service price ledger itself. Prices for certain diagnostic or laboratory services were occasionally missing for specific years, even though prices for the same service were listed in other years, apparently unrelated to patient characteristics or clinical outcomes. In these cases, the cost of the affected service could not be calculated directly for patients treated that year. Such gaps were most common for laboratory and radiological services, whereas no price entries were missing for OR, endoscopy, ward or ICU costs. The number of missing price entries and affected patients, by year and service category, are reported in Table S1.

The total cost of surgical care used in analyses comprised itemized subcosts for: perioperative radiological imaging, operation room (OR) cost, postoperative ward days, intensive care unit (ICU) days, endoscopies, interventional radiology procedures, and reoperations within 90 days postoperatively. OR cost was determined based on the surgical procedure code, matched to the corresponding price in the hospital’s itemized service price ledger. OR service price, representing the OR cost, included operating and recovery room utilization and staff, instrumentation, disposables, drugs and other consumables, and the facility overhead. For ICU stays, the mean prices of normal and extra-demanding ICU days were used, since retrospective distinction was not possible.

Statistical analysis

Statistical analyses were performed using Statistical Package for Social Sciences (SPSS, version 30.0, IBM Corp) and Python, with stats models and NumPy. Descriptive statistics were calculated using patient-level cost data. Annual summaries were computed by treatment year, and for each year the mean, standard deviation, median, minimum, and maximum costs were calculated. Non-numeric or invalid values were treated as missing and excluded from calculations.

Postoperative complication severity was defined using Clavien-Dindo classification (13). For descriptive reporting of cost by complication grade, patients were categorized into three groups: no complications (grade 0), minor complications (grade I–II) and major complications (grade III–V). For the regression analyses, patients were grouped into two categories: no or minor complications (grades 0–II) and major complications (grades III–V), comprising 223 and 180 patients, respectively.

To enable comparison across years, all cost estimates were adjusted for inflation according to 2013 price levels. Inflation adjustment was performed by multiplying all annual summary statistics by predefined year-specific inflation factors, with 2013 serving as the reference year. All results are reported as inflation-adjusted costs. Comparisons between groups were made using the chi-square test. Mann-Whitney and Kruskal-Wallis tests were used to analyze continuous data. Shapiro-Wilk’s test was used to analyze data distribution.

Quantile regression was used to identify factors associated with high total treatment costs. The 75th percentile was selected to represent the upper-cost segment while retaining greater precision than more extreme quantiles. Separate models were fitted for patients with no or minor complications (Clavien-Dindo grades 0–II) and major complications (grade III or higher). Exponentiated coefficients are reported as conditional 75th-percentile cost ratios (CRs) with 95% confidence intervals (CIs). Selected covariates included the Charlson Comorbidity Index, previous alcohol consumption, previous smoking, preoperative weight loss, pathological diagnosis, vascular reconstruction, and resection type. American Society of Anaesthesiologists (ASA) class, World Health Organization (WHO) performance status, clinical frailty scale, and tumor location were considered but excluded to reduce the number of covariates. The retained covariates were selected based on their clinical relevance to comorbidity, nutritional status, operative complexity, postoperative recovery and resource use. No univariable screening or stepwise selection was used. Missing predictor values were addressed using 20 imputations performed separately within each complication group, and complete-case analyses were performed as sensitivity analyses. Benjamini-Hochberg false discovery rate correction was applied separately within each model. Individual cost components were analyzed descriptively without separate hypothesis testing

Linear regression was applied to assess the annual change in median total cost per patient across the study period (2013–2021). This method was chosen to evaluate whether costs changed progressively over the study period or reflected a change confined to a single year. Given that 2021 was an atypical year, affected by the coronavirus disease 2019 (COVID-19) pandemic, and the onset of high inflation in Finland, alongside an unusual peak in endoscopy costs, a sensitivity analysis was additionally performed with 2021 excluded.

Results

A total of 403 patients underwent pancreatic resection at Oulu University Hospital during years 2013–2021. Patient characteristics are shown in Table 1. Median patient age was 67 years, and 54.1% were male. Median body mass index was 25.5 kg/m². CCI was 1–2 in 59.1% of patients. Surgical indication was most often pancreatic, biliary or duodenal malignancy (82.5%). The most frequent procedure was pancreatoduodenectomy (66.7%), followed by open distal pancreatectomy (18.4%), laparoscopic distal pancreatectomy (9.4%), and total pancreatectomy (5.5%). Median intraoperative bleeding was 600 mL, and the duration of surgery 8 h 9 min. Reoperation was required in 12.9% of cases, and 18.6% of patients received transfusions. The most common complications were delayed gastric emptying/ileus (15.4%), postoperative chyle leak (12.4%), and postoperative pancreatic fistula (9.4%). The operational data are shown in Table 2.

Table 1. Patient characteristics.

Variable	Values
Age (years), median	67
Sex, n (%)
Female	185 (45.9)
Male	218 (54.1)
BMI (kg/m2), median	25.5
Tobacco use, n (%)	101 (36.1)
Alcohol use, n (%)	32 (12.5)
DM, n (%)	107 (26.6)
Pulmonary condition, n (%)	66 (16.4)
ASA, n (%)
1	19 (4.7)
2	190 (47.3)
3	183 (45.5)
4	10 (2.5)
Malignant indication for surgery, n (%)	330 (82.5)
CCI, n (%)
0	127 (31.5)
1–2	238 (59.1)
3–4	32 (7.9)

N=403 unless otherwise indicated, denominators reflect the number of patients with available data (tobacco use: n=280, alcohol use: n=256, diabetes mellitus: n=402, ASA class: n=402). ASA, American Society of Anaesthesiologists; BMI, body mass index; CCI, Charlson Comorbidity Index; DM, diabetes mellitus.

Table 2. Procedural characteristics.

Variable	Values
Surgery type (n=403), n (%)	403
Pancreatoduodenectomy	269 (66.7)
LAP distal pancreatectomy	38 (9.4)
Open distal pancreatectomy	73 (18.4)
Total pancreatectomy	22 (5.5)
Intraoperative bleeding, mL, median	600
Intraoperative RBC transfusions, n (%)	75 (18.6)
Postoperative RBC transfusions, n (%)	109 (27.2)
Reoperation, n (%)	52 (12.9)
Duration of operation, median	8 h 9 min
POPF, n (%)	38 (9.4)
Chyle leak, n (%)	50 (12.4)
Bile leak, n (%)	14 (3.5)
DVT or PE, n (%)	30 (7.5)
Ileus or DGE, n (%)	62 (15.4)
Wound infection, n (%)	29 (7.2)
No. of vascular reconstructions (% of total surgeries)
2013–2015	16 (18.6)
2016–2018	19 (13.5)
2019–2021	57 (32.4)

DGE, delayed gastric emptying; DVT, deep vein thrombosis; LAP, laparoscopic; PE, pulmonary embolism; POPF, postoperative pancreatic fistula; RBC, red blood cell.

The median total cost of pancreatic surgery was €23,521. The largest cost components were the OR cost (median €10,659) and postoperative ward care (median €6,677). Median costs for utilization of endoscopies, radiological examinations, and laboratory services were €1,656, €1,048, and €632 per patient, respectively. The distribution of costs between different services is presented in Table 3. Total cost per patient, as well as all subcost types, were significantly correlated with complications (P<0.05 for all subcosts) and their severity. Treatment of patients without complications (Clavien-Dindo grade 0) resulted in a total median cost of €18,303, while expenses for patients with mild (Clavien-Dindo grades I–II), and severe complications (Clavien-Dindo grades III–V) reached €23,074, and €29,507, respectively (Table 4).

Table 3. Cost distribution in subcategories.

Cost category	Cost, €
Procedural cost (operation room), median	10,659
Ward care, median	6,677
Radiological imaging + interventions, median	1,048
Intensive care unit, mean ± standard error	2,306±5,660
Endoscopy, median	1,656
Laboratory, median	632
Overall, median	23,521

Table 4. Median costs of complications.

Cost category	C-D 0	C-D I–II	C-D III–V	P value
OR	9,302	10,659	10,659	0.01
Ward care	5,510	7,284	7,714	<0.001
Imaging + radiological interventions	770	812	1,481	<0.001
ICU	0	0	4,680	<0.001
Endoscopy	1,592	1,656	2,512	0.005
Laboratory	372	638	1,132	<0.001
Total	18,303	23,074	29,507	<0.001
Surgery type
Pancreatoduodenectomy	20,056	24,207	30,442	<0.001
LAP distal pancreatectomy	14,192	13,328	26,188	0.008
Open distal pancreatectomy	12,861	14,488	22,910	<0.001
Total pancreatectomy	17,343	30,076	29,470	0.32
POPF	0	21,557	33,090	–
DGE	0	24,706	35,477	–
Chyle leak	0	24,135	30,733	–
Bile leak	0	25,323	37,434	–
Ileus	0	14,965	37,424	–
DVT	0	27,181	32,836	–
PE	0	18,801	32,078	–

C-D, Clavien-Dindo classification; DGE, delayed gastric emptying; DVT, deep vein thrombosis; ICU, intensive care unit; LAP, laparoscopic; OR, operation room; PE, pulmonary embolism; POPF, postoperative pancreatic fistula.

A total of 223 patients had no or minor complications, and 180 had major complications. The primary multiple-imputation analyses included all patients, whereas the complete-case analyses included 115 and 84 patients, respectively. In patients with no or minor complications, distal pancreatic resection was associated with a lower conditional 75th-percentile total cost than pancreatoduodenectomy (CR, 0.62; 95% CI, 0.53–0.72; P<0.001; adjusted P<0.001). Total pancreatectomy was associated with a higher cost before correction for multiple testing (CR, 1.47; 95% CI, 1.04–2.07; P=0.03), but not after false discovery rate correction (adjusted P=0.166). The complete-case analysis showed similar associations for distal pancreatic resection (CR, 0.55; 95% CI, 0.48–0.64; adjusted P<0.001) and total pancreatectomy (CR, 1.49; 95% CI, 1.11–2.01; adjusted P=0.03). Among patients with major complications, vascular reconstruction was associated with a higher conditional 75th-percentile total cost before correction for multiple testing (CR, 1.23; 95% CI, 1.02–1.47; P=0.03). However, the association did not remain significant after false discovery rate correction (adjusted P=0.32).

Development of total costs over time showed a progressively rising trend after centralization, as depicted in Figure 1A. A comparable trend can be observed in patients with and without complications (Figure 1B). The subcosts for radiological imaging and interventions, and laboratory testing remained stable. However, the OR costs (€8,941 in 2013 vs. €15,136 in 2021), postoperative ward costs (€4,480 vs. €7,450) and endoscopy costs (€1,755 vs. €7,615) rose significantly (P<0.001) during the study period. The total costs increased by €11,190 per pancreatectomy patient in 2013–2021.

Figure 1.

Annual trends in treatment costs by cost category and complication severity. (A) Itemized cost development; (B) cost development in relation to complications.

Development of total costs over time showed a progressive increase across the study period. Median total cost per patient increased by €2,034 per year (95% CI, 1.55–2.52, P<0.001) between 2013 and 2021. This trend remained significant after excluding 2021, with median costs increasing by €1,529 per year (95% CI, 0.95–2.10, P<0.001).

The volume of vascular reconstructions increased significantly from 16 to 57 cases between 2013–2015 and 2019–2021 (P<0.001, Table 2). Vascular reconstructions were associated with higher median costs (€27,683 vs. €22,401, P<0.001). Although complication rates were higher in this group (80.4% vs. 70.1%), the difference reached only borderline significance (P=0.051, Table 5).

Table 5. Comparison of postoperative complications and total costs between patients with and without vascular reconstruction.

Variable	No vascular reconstruction (n=311)	Vascular reconstruction (n=92)	P value
Complications, n (%)			0.051
No	93 (29.9)	18 (19.6)
Yes	218 (70.1)	74 (80.4)
Total cost (€), median	22,401	27,683	<0.001

Discussion

Key findings

Our study aimed to characterize how costs evolved during the first years following centralization, and to identify which components accounted for the change. We explored a detailed cost breakdown of hospital services provided to patients undergoing pancreatectomy during the first decade after centralization. Our main finding was a constant rise in the inflation-adjusted total costs. Specifically, the OR costs, and less prominently, the postoperative ward costs showed a progressive increase. Besides the increased rate of postoperative endoscopies, procedures aimed at managing postoperative complications, such as reoperations, radiological imaging, and radiological interventions, showed no increase during the study period. The rise in endoscopy costs is mainly explainable by the implementation of advanced endoscopic ultrasound-guided procedures in complication management during the last decade, producing an outlier year of 2021 with a high peak in endoscopy expenses. Complications were significantly associated with higher costs, as expected. Among patients with no or minor complications, the regression analysis identified procedure type as the main driver of costs, with distal pancreatic resection associated with lower costs than pancreatoduodenectomy.

Strengths and limitations

This was a single-centre retrospective study, limiting generalizability to other hospitals with different case volumes, costs, and perioperative protocols. Costs were derived from institutional tariffs rather than micro-costing of actual resource consumption. Tariffs represent standardized accounting charges and may not fully capture the true marginal cost of individual services. Inflation was accounted for, and yearly price lists were used. Data were collected from hospital databases, and while reviewed twice, errors may remain. Some prices were missing and were estimated by averaging adjacent years. The strength of the study is in its highly detailed cost breakdown, including even laboratory costs per patient. Elaborate itemized costing has rarely been applied in previous analyses (6,14), but instead only crude prices have been applied; thus, error sources are more abundant.

The most important limitation of our design is the absence of a pre-centralization comparison group. Because the cohort covers only the years following centralization, we can describe how costs evolved within a centralized unit but cannot attribute the observed increase to centralization itself, nor separate it from concurrent changes in case mix, surgical technique and wage levels.

Comparison with similar research

Our central finding is the steep, inflation-independent rise in the total costs of pancreatic surgery across the first decade following centralization. The result should be evaluated against the heterogeneous literature on economics of centralization. Several issues limit the generalizability of the cost analyses investigating the effect of centralization. Primarily, the majority of studies are designed to compare costs between HVHs and LVHs, with no existing, and accepted definition for HVH. Thus, used HVH definitions range vastly from 10–70 pancreaticoduodenectomies per year, with the lower end of the spectrum not reflecting the real-world setting of pancreatic surgery services, and the heterogeneity further restricting the usefulness of the reports in meta-analyses. Additionally, these studies are either register-based studies of multi-center reports set to compare costs between different hospitals and institutions, with highly varied billing systems, cost records, and perioperative processes, that preclude the assessment of isolated cost-volume effect and comparison between heterogeneous variables. A retrospective single-center setting, with detailed data collection and a time trend analysis such as in this study, is thus a reasonable approach to the consequences of centralization. However, since our study covers only the post-centralization period, we cannot isolate the effect of centralization itself from other concurrent changes. The most significant simultaneous development of the last decade in pancreatic surgery is no doubt the expansion of surgical complexity, including the growing use of oncovascular techniques and increasing resection rates worldwide.

Patients with Clavien-Dindo grades III–V complications had significantly (P<0.001) higher expenses than those without complications (Clavien-Dindo grade 0) or with only mild complications (Clavien-Dindo grades I–II) also in our study. For Clavien-Dindo grades III–V patients, all subcost categories showed consistently higher costs, with patients undergoing ICU admissions, prolonged ward stays, and additional diagnostic and therapeutic interventions. These findings are in line with previous work. In a national analysis of 37,893 pancreatectomy patients, Alterio et al. (2023) used a quantile regression model to assess costs across the cost distribution and found that major complications nearly doubled hospital costs at the median, and magnified them further at the upper end of the distribution (15). A recent systematic review of 46 studies confirmed that costs rise with increasing complication severity (6), and a similar severity gradient has been reported after distal pancreatectomy (16).

In patients with no or minor complications, procedure type was the dominant cost driver, with distal pancreatectomy associated with lower conditional 75^th-percentile cost. The difference persisted after correction for multiple testing. The association is consistent with shorter operative time and length of stay for uncomplicated distal (open or mini-invasive) resections compared with pancreatoduodenectomy, with prior work reporting shorter hospital stay and lower resource use for distal pancreatectomy than for pancreatoduodenectomy within the same healthcare system (17).

Vascular reconstruction was associated with higher median costs (€27,683 vs. €22,401). In patients with major complications, vascular reconstruction likewise was associated with a higher conditional 75^th-percentile cost, but the significance did not survive false discovery rate correction. The direction of this finding is, however, in agreement with Barreto et al., who reported that synchronous venous reconstruction increased the cost of pancreatoduodenectomy independently of hospital stay (18). Together, these observations suggest that vascular reconstruction contributes to cost increase partly through the procedure itself, rather than solely through a more difficult postoperative course. Given the loss of significance after correction in our cohort, this association should be interpreted with strict caution.

Explanations of findings

OR cost is a multifactorial expense that includes several indirect expenses, such as physicians, nurses and other staff labor during surgery, operating and recovery room utilization, disposable supplies, medications, instruments, and facility overhead (19). In our data, the duration of surgery increased significantly during the study period, most likely due to the introduction of oncovascular surgery. Consumption of supplies, instruments and medications most likely remained largely constant; however, a precise assessment of their utilization would require a prospective inventory of patients’ OR visits and could not be performed retrospectively. An exception to unchanged consumption practices of instruments occurred with the commencement of laparoscopic distal pancreatectomies, which took place in 2008–2009 at Oulu University Hospital. The rate of laparoscopic pancreatectomies has steadily increased during the study period. In our data, the OR cost in laparoscopic procedures was slightly higher compared to open distal pancreatectomies (€14,192 vs. €12,860), probably reflecting the higher costs of laparoscopic staplers and tissue fusion instruments, which aligns with previous studies (14,20).

Although inflation-adjusted, the reported costs showed a constant rise during the study period. During years 2013–2020, inflation in Finland remained at a reasonable <2% level, while general wage raises were even lower (21,22). However, according to Statistics Finland, wage raises for physicians and nursing staff exceeded the index rises by 3–5% during 2013–2020. Thus, considering that staff expenses comprise the most significant subcategory of any public cost infrastructure, the wage raises during the study period, although very moderate, likely also contribute to the increased costs.

Implications and actions needed

Rising costs after centralization appear to reflect various concurrent changes in societal structures and perioperative practices, such as above-inflation wage raises, implementation of mini-invasive surgery, and oncovascular techniques, alongside centralization. OR costs and ward expenses are the major cost contributors with the steepest increase as a function of time. Since the procedure type is the only cost driver that persists after correction for multiple testing, cost-reduction efforts should target OR utilization and ward-level care pathways.

Conclusions

Costs of pancreatic surgery rose steadily during the first decade following centralization, despite a stable complication rate. In quantile regression analysis, only procedure type remained a significant cost driver after correction for multiple testing. OR costs and postoperative ward care accounted for most of the rising expenses.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the University of Oulu (No. EETTMK 81/2008). The National Authority for Medicolegal Affairs (VALVIRA) has approved the use of data and samples and thus waived the need for informed consent.

Data Sharing Statement

Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-0637/dss

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DOI: 10.21037/jgo-2026-0637