Achieving Textbook Outcomes in Pancreatic Cancer Surgeries: A Case for Balancing Centralization and Access in Low-Resource Settings.

Centralization is associated with improved outcomes in pancreatic surgery. However, its feasibility in low- and middle-income countries (LMICs) is uncertain due to logistic and infrastructural constraints. This study evaluates outcomes from a tier-II, low-volume centre using textbook outcome (TO) as a composite quality metric. A retrospective analysis of a prospectively maintained database (2019-2024) was performed. Textbook outcome was defined according to van Roessel et al. All perioperative outcomes were reported descriptively. Eighty patients underwent pancreatic resections during the study period. Clinically relevant postoperative pancreatic fistula occurred in 10%, delayed gastric emptying in 16.3%, post-pancreatectomy haemorrhage (B/C) in 3.7%, and major morbidity (Clavien-Dindo ≥ III) in 17.5%. In-hospital mortality was 6.3%. Textbook outcome was achieved in 73.8% of patients. Pancreatic surgery can be performed with acceptable outcomes in a lower-volume centre when standardized techniques and structured perioperative protocols are followed. However, the higher mortality and failure-to-rescue rates underscore the need for strengthening critical-care systems and early-escalation pathways. Expanding surgical capacity beyond metropolitan centres must be accompanied by corresponding investments in postoperative support infrastructure.